Near misses are often referred to as “close-calls” or “good catches.” They’re potentially harmful events that never reach the patient. Nurses catch them every day, often because the nurse is the last link to the patient. Conversely, when nurses do not catch errors, the nurse has historically taken the blame rather than the 12 other health care professionals before him, the system/process, the drug manufacturer, etc.

Chasity Burrows Walters, MSN, RN, of Memorial Sloan-Kettering Cancer Center (MSKCC) authored “Near Misses: Free Lessons for Safer Care” in the Best Practices section of the July 2010 Oncology Nurse Edition. (I would link you directly to the article, but it’s not archived yet.)

She discussed how vital it is for nurses to report near misses so facilities can learn and improve safety systems. Medical facilities are utilizing anonymous, electronic near miss reporting to fairly capture these potentially deadly events. She even shared near miss data from MSKCC. Kudos to her and MSKCC for leading patient safety so boldly.

How does your facility capture, learn from, and report back near misses?