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 (4)

•Diagnostic Errors (3)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (8)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (43)

•Medical Complications (8)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (20)

•Transfusion Complications (2)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (3)

•Europe (17)

•North America (97)

Resource Types

•Book/Report (5)

•Journal Article (104)

•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 (21)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (81)

•Communication Improvement (30)

•Human Factors Engineering (19)

•Teamwork (6)

•Specialization of Care (3)

•Logistical Approaches (9)

•Culture of Safety (17)

•Technologic Approaches (16)

•Education and Training (21)

Clinical Areas

•Allied Health Services (2)

•Medicine (91)

•Nursing (20)

•Pharmacy (14)

Target Audience

•Health Care Providers (93)

•Health Care Executives and Administrators (98)

•Non-Health Care Professionals (36)

•Patients (1)

Setting of Care

•Hospitals (78)

•Psychiatric Facilities (2)

•Residential Facilities (1)

•Ambulatory Care (11)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 123

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STUDY

Safety climate and medical errors in 62 US emergency departments.

Camargo CA Jr, Tsai CL, Sullivan AF, et al. Ann Emerg Med. 2012;60:555-563.e20.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds.

Cohen T, Blatter B, Almeida C, Patel VL. J Am Med Inform Assoc. 2007;14:312-319.

STUDY

Medication errors in paediatric outpatients.

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

NEWSPAPER/MAGAZINE ARTICLE

Washington Hospital Center safety program seeks to catch 'near-misses.'

Sun LH. Washington Post. August 2, 2011.

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Pediatrics. 2005;116:603-608.

STUDY

Catching and correcting near misses: the collective vigilance and individual accountability trade-off.

Jeffs LP, Lingard L, Berta W, Baker GR. J Interprof Care. 2012;26:121-126.

STUDY

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

Taylor JA, Brownstein D, Klein EJ, Strandjord TP. J Hosp Med. 2007;2:226-33.

STUDY

The nature and occurrence of registration errors in the emergency department.

Hakimzada AF, Green RA, Sayan OR, Zhang J, Patel VL. Int J Med Inform. 2008;77:169-175.

STUDY

Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

Graham DG, Harris DM, Elder NC, et al. Qual Saf Health Care. 2008;17:201-208.

STUDY

Analysis and prioritization of near-miss adverse events in a radiology department.

Thornton RH, Miransky J, Killen AR, Solomon SB, Brody LA. AJR Am J Roentgenol. 2011;196:1120-1124.

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.

NEWSPAPER/MAGAZINE ARTICLE

The near miss.

Clark C. HealthLeaders Media. December 2012.

STUDY

Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs.

Ranchon F, Salles G, Späth HM, et al. BMC Cancer. 2011;11:478.

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.

COMMENTARY classic

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

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

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.

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

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

BOOK/REPORT

Department of Defense Health Care Quality.

Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.

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