Regional Ambulatory Near Miss Reporting and Tracking to

Improve Patient Safety--AHRQ

Near-Miss Project (NMP)

Practice Kick-Off

What is a near-miss event?

A deviation from a planned or expected

process of care that COULD have resulted in

harm to the patient, but was averted before

ANY harm was done.

Something happens that we didn’t intend, and. . .

There is SOME potential for harm, but. . .

NO HARM (even minor) to the patient

Examples

Rx for amoxcillin sent to pharmacy; pharmacist calls to remind prescriber of reported penicillin allergy; Rx changed.

Lab report misfiled in another patient’s chart without review from the ordering provider; found by chance when other patient seen in clinic the following day

Was this a deviation? Potential for harm?

No patient harm?

Other examples

Patient trips on a loose floor tile and bruises her leg. Able to get up on her own and walk out of the clinic without difficulty.

Patient is given the wrong date on her appointment card and has to be rescheduled. She leaves upset.

Was this a deviation? Potential for harm? No patient harm?

So what?

Most medical encounters take place in ambulatory settings

We don’t know very much about near-miss events in practice—they’re probably very common.

Near misses may represent low-risk opportunity to find and fix problems BEFORE patients are harmed.

Who is doing this research study?

AHRQ—Agency for Health Research on Quality (a division of the NIH)

Primary Investigator—Steve Crane, MD MAHEC, UNC-CH

Why is our practice participating in this study?

Because we want our practice to be the safest place possible for patients

And because we’re all patients at some point and need ALL area practices to be safer.

Who should report a near miss event?

ALL OF US!

(Anyone who has contact with patients, and observes a near miss event.)

How do I report a near-miss event?

Click the near-miss icon on your computer desk-top (see next slide)

Fill out the on-line form

IT’S EASY! (it shouldn’t take more than a couple of minutes)

The Near Miss Desktop Icon

Example of reporting form

When do I fill out the report?

As close to the time you observe the event or become aware of it.

But NOT to interfere with your other duties to patients in the clinic.

What should I put in the report?

Answer the questions simply, and the best you can.

Do NOT put any patient specifics that could allow someone to know who the patient is (no names, dates of birth, medical record numbers, etc.)

What happens to the report?

Each report will be reviewed by our practice leaders.

YOUR report is IMPORTANT for us to find things we can fix in our practice to make it safer!

Is there any risk to me to report?

NO!! Reports are COMPLETELY anonymous.

We WANT to know what doesn’t go right so we can fix it!

How do I report an event where the patient IS harmed?

Use the Adverse Event Reporting procedure for our practice.

Do NOT use the Near Miss Reporting system for this purpose.

What if I’m not sure if the event is a near-miss?

If in doubt, REPORT!

We can’t fix what we don’t know about.

Goals for our practice

At least TEN (10) near miss reports a month for the next 6 months for the whole practice (about 2 a week).

Even better, ALL the near miss events that happen in our practice get reported.

(remember, we can’t fix what we don’t know about!)

Other things I might be asked to do

Fill out two short surveys about our practice environment (these are also anonymous).

Sit down for a short confidential interview (10 minutes) with the researcher to get more information about how we think about near miss events in this practice.*

*this is voluntary

Near Miss Reporting Project

Making our practice the SAFEST place for our patients

Questions and Discussion