AHRQ Patient Safety Network

The Collection > Near Miss

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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 (5)

•Diagnostic Errors (2)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (7)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (38)

•Medical Complications (7)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (16)

•Transfusion Complications (2)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (3)

•Europe (16)

•North America (84)

Resource Types

•Book/Report (6)

•Journal Article (94)

•Newspaper/Magazine Article (9)

•Press Release/Announcement (2)

•Web Resource (1)

Error Types
< All

Near Miss

Approach to Improving Safety

•Quality Improvement Strategies (19)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (74)

•Communication Improvement (23)

•Human Factors Engineering (19)

•Teamwork (4)

•Specialization of Care (2)

•Logistical Approaches (10)

•Culture of Safety (17)

•Technologic Approaches (16)

•Education and Training (22)

Clinical Areas

•Allied Health Services (3)

•Medicine (80)

•Nursing (18)

•Pharmacy (10)

Target Audience

•Health Care Providers (89)

•Health Care Executives and Administrators (92)

•Non-Health Care Professionals (33)

Setting of Care

•Hospitals (73)

•Psychiatric Facilities (2)

•Residential Facilities (1)

•Ambulatory Care (9)

•Outpatient Surgery (2)

•Patient Transport (2)

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COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Check the Wristband.

Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

Patient Mix-Up.

Shojania KG. AHRQ WebM&M [serial online]. February 2003.

STUDY

Cardiovascular medication errors in children.

Alexander DC, Bundy DG, Shore AD, Morlock L, Hicks RW, Miller MR. Pediatrics. 2009;124:324-332.

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.

COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

BOOK/REPORT

Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.

Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.

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.

NEWSPAPER/MAGAZINE ARTICLE

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

COMMENTARY

Caution, Interrupted.

Wears RL. AHRQ WebM&M [serial online]. September 2004.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

STUDY

Medication errors in paediatric outpatients.

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

COMMENTARY

Moved Too Soon.

Lindenauer P. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

COMMENTARY

Listen to the Family.

Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.

STUDY

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

Smith ML, Raab SS. Arch Pathol Lab Med. 2011;135:1436-1440.

STUDY

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ford EC, Smith K, Harris K, Terezakis S. Med Phys. 2012;39:6968-6971.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

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