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Near Miss
PATIENT SAFETY PRIMERS
Glossary
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Near Miss:
An event or situation that did not produce patient injury, but only because of chance...
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Device-related Complications (6)
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Diagnostic Errors (1)
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Identification Errors (13)
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Discontinuities, Gaps, and Hand-Off Problems (7)
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Fatigue and Sleep Deprivation (2)
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Medication Safety (35)
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Newspaper/Magazine Article (10)
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Near Miss
Approach to Improving Safety
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Hospitals (63)
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COMMENTARY
The Dangerous Detour.
Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.
COMMENTARY
Reporting near-miss events in nursing homes.
Wagner LM, Capezuti E, Ouslander JG. Nurs Outlook. 2006;54:85-93.
BOOK/REPORT
A safer place for patients: learning to improve patient safety.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
STUDY
Near misses: paradoxical realities in everyday clinical practice.
Jeffs L, Affonso DD, Macmillan K. Int J Nurs Pract. 2008;14:486-494.
NEWSPAPER/MAGAZINE ARTICLE
A long way to go.
DerGurahian J. Mod Healthc. December 7, 2009.
COMMENTARY
Moved Too Soon.
Lindenauer P. AHRQ WebM&M [serial online]. October 2004.
STUDY
The application of Aronson's taxonomy to medication errors in nursing.
Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.
COMMENTARY
Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
COMMENTARY
Patient Mix-Up.
Shojania KG. AHRQ WebM&M [serial online]. February 2003.
COMMENTARY
Back to Basics
Hellman R. AHRQ WebM&M [serial online]. March 2007.
COMMENTARY
Right Patient, Wrong Sample
Astion M. AHRQ WebM&M [serial online]. December 2006.
COMMENTARY
Flying Object Hits MRI.
Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.
STUDY
Health care work environments, employee satisfaction, and patient safety: care provider perspectives.
Rathert C, May DR. Health Care Manage Rev. 2007;32:2-11.
COMMENTARY
HomeNet: ensuring patient safety with medical device use in the home.
Kaufman D, Weick-Brady M. Home Healthc Nurse. 2009;27:300-307.
NEWSPAPER/MAGAZINE ARTICLE
Program encourages reporting accidents waiting to happen: the Good Catch Awards.
McCook A. Anesthesiology News. Sept 2011;37:9.
NEWSPAPER/MAGAZINE ARTICLE
Drug shortages: national survey reveals high level of frustration, low level of safety.
ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010;15,1-6.
STUDY
Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study.
Tanaka M, Tanaka K, Takano T, Kato N, Watanabe M, Miyaoka H. BMJ Qual Saf. 2012;21:784-790.
COMMENTARY
Check the Wristband.
Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.
STUDY
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
COMMENTARY
Computerization can create safety hazards: a bar-coding near miss.
McDonald CJ. Ann Intern Med. 2006;144:510-516.
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