Near Misses, Far Catches

What is the best approach in gathering accurate and actionable information regarding "near misses" in a hospital setting?

Reporting "near misses" should be a basic expectation in a healthcare provider environment. However, if a punitive culture exists staff are less likely to report these events. Furthermore, if the reporting process is complex and involves paper-pushing, a higher degree of under reporting may result.

Indeed, "near misses" do occur in hospitals (i.e. patient falls and medication administration errors) Yet, when they happen, are the proper individuals alerted? If so, does the alert initiate a timely response so that education and process improvement are executed to minimize a repeat event? It is imperative that the healthcare quality professional evaluate the processes and systems that bottleneck this reporting and find remedies.

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The current literature claims that an effective "near miss" reporting process is an essential element to a first-rate hospital quality program.

In synthesis, the mechanism (paper or electronic) a hospital chooses in reporting "near misses" is equally significant to how the information is managed and aimed toward to continuous improvement.