Near Misses Experienced at a University Hospital in Korea

Park, Mi-Hyang; Kim, Hyun-Joo; Lee, Bo-Woo; Bae, Seok-Hwan; Lee, Jin-Yong

doi:2016.22.1.41

Qual Improv Health Care > Volume 22(1); 2016 > Article

Quality Improvement in Health Care 2016;22(1): 41.
DOI: https://doi.org/10.14371/QIH.2016.22.1.41 Published online June 30, 2016.

Near Misses Experienced at a University Hospital in Korea

Mi-Hyang Park¹, Hyun-Joo Kim², Bo-Woo Lee¹, Seok-Hwan Bae³, Jin-Yong Lee^4,5

¹Department of Public Health, The Graduate School of Konyang University
²Department of Nursing Science, Shinsung University
³Department of Radiological Science, College of Medical Science, Konyang University
⁴Public Health Medical Service, Boramae Medical Center, Seoul National University College of Medicine

Abstract

Objectives
This study aimed to investigate how many healthcare professionals experienced near misses, what types of near misses occurred most often, and healthcare professionals' opinions about near misses at one university hospital in Korea.
Methods
The authors developed a questionnaire including 26 core types of near misses and 4 questions about preventability and reporting barriers. The survey was conducted from Oct. 31st to Nov. 18th 2011, about 3 weeks, using a self-administrated questionnaire that was administered to 697 healthcare professionals (registered nurses, pharmacists, technicians, and nurses aides) who worked at a university hospital. Medical doctors and employees working in the department of administration were excluded.
Results
About half of hospital workers experienced at least one or more near misses during the past one year. The drug dispensing process was the most common subcategory of near misses. Among the 26 items, patient falls was highest. Over 95% of respondents reported that the near miss they experienced was preventable. Also, more than half of respondents did not report the near miss and the main reason for omission was fear of blame.
Conclusion
Regarding patient safety issues, a near miss is a very significant factor because it can be a potential adverse event. Therefore, we should grasp the size of the problem through tracking and analyzing near misses and should make an effort to reduce them. To do so, we should check whether our reporting system is well designed and functioning.

Key words Near misses;Adverse events;Patient safety;Health professionals;Reporting system;