AHRQ Patient Safety Network

The Collection > Near Miss

Glossary >
Near Miss: An event or situation that did not produce patient injury, but only because of chance... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (3)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (9)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (47)

•Medical Complications (8)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (20)

•Transfusion Complications (2)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (3)

•Europe (20)

•North America (102)

Resource Types

•Book/Report (6)

•Journal Article (116)

•Newspaper/Magazine Article (11)

•Press Release/Announcement (2)

•Web Resource (1)

Error Types
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Near Miss

Approach to Improving Safety

•Quality Improvement Strategies (23)

•Legal and Policy Approaches (6)

•Error Reporting and Analysis (88)

•Communication Improvement (31)

•Human Factors Engineering (23)

•Teamwork (6)

•Specialization of Care (3)

•Logistical Approaches (11)

•Culture of Safety (19)

•Technologic Approaches (19)

•Education and Training (25)

Clinical Areas

•Allied Health Services (3)

•Medicine (99)

•Nursing (24)

•Pharmacy (15)

Target Audience

•Health Care Providers (103)

•Health Care Executives and Administrators (109)

•Non-Health Care Professionals (38)

•Patients (1)

Setting of Care

•Hospitals (84)

•Psychiatric Facilities (3)

•Residential Facilities (2)

•Ambulatory Care (13)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 136

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STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.

Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-87.

STUDY

Do medical inpatients who report poor service quality experience more adverse events and medical errors?

Taylor BB, Marcantonio ER, Pagovich O, et al. Med Care. 2008;46:224-228.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

REVIEW

Human factor in cardiac surgery: errors and near misses in a high technology medical domain.

Carthey J, de Leval MR, Reason JT. Ann Thorac Surg. 2001;72:300-305.

STUDY

Incidence of adverse drug events and potential adverse drug events: implications for prevention.

Bates DW, Cullen DJ, Laird N, et al; ADE Prevention Group. JAMA. 1995;274:29-34.

STUDY

National survey on the effect of oncology drug shortages on cancer care.

McBride A, Holle LM, Westendorf C, et al. Am J Health Syst Pharm. 2013;70:609-617.

STUDY

Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic errors in medicine.

Ogdie AR, Reilly JB, Pang WG, et al. Acad Med. 2012;87:1361-1367.

STUDY

Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.

de Vries EN, Prins HA, Bennink MC, et al. BMJ Qual Saf. 2012;21:503-508.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

COMMENTARY

Disclosure of "nonharmful" medical errors and other events: duty to disclose.

Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Arch Surg. 2012;147:282-286.

BOOK/REPORT

The Value of Close Calls in Improving Patient Safety.

Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158.

STUDY

A novel approach to increase residents' involvement in reporting adverse events.

Scott DR, Weimer M, English C, et al. Acad Med. 2011;86:742-746.

COMMENTARY classic

The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events.

Chang A, Schyve PM, Croteau RJ, O’Leary DS, Loeb JM. Int J Qual Health Care. 2005;17:95-105.

STUDY

Medication errors in paediatric outpatients.

Kaushal R, Goldmann DA, Keohane CA, et al. Qual Saf Health Care. 2010;19:e30.

STUDY

Medication errors involving oral chemotherapy.

Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

STUDY

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN. Arch Dis Child. 2010;95:286-290.

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