BioScience Trends. 2010;4(5):231-238.

Nurse risk managers' criteria for dealing with near-miss events.

Kodama S, Kanda K


From the preventive point of view, it is very valuable for Japanese hospital safety managers to select important cases not only from among accident events, but also from near-miss events that involve errors that may result in the occurrence of future serious adverse events. The objective of this study is to investigate factors that determine the type of analysis that applies to hypothetical near-miss events. We sent self-administered questionnaires to 393 nurse risk managers from general hospitals in Japan. Hypothetical near-miss events were presented, and respondents assessed hypothetical events. Type of Analysis, Probability, Organizational Risk (effect on reputation and effect on cost), and Severity (possibility of harm, degree of harm, possibility of recovery, and possibility of delayed discharge) were included in the questionnaire. Response rate was 47.3% (186/393) and finally 175 nurses are analyzed. The respondents were 58 full-time safety managers (33.1%) and 117 who were safety managers concurrently with other work (66.9%). As a result of logistic regression analysis, probability, effect on reputation, possibility of harm and possibility of delayed discharge were significant (p < 0.05). Japanese safety managers consider near-miss events that have a lower probability to be more important. This finding differs from existing prioritization systems that were principally made for actual adverse events. It may suggest the problem of uncritically applying scales for accident events to near-miss events.

KEYWORDS: Patient safety, risk management, adverse event, near-miss, incident report

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