Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

Lianne Jeffs; Whitney Berta; Lorelei A. Lingard; Ross Baker

Study

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

March 7, 2012

Jeffs L, Berta W, Lingard LA, et al. BMJ Qual Saf. 2012;21(4):287-94.

View more articles from the same authors.

This study identified three different scenarios associated with organizational responses to near misses.

PubMed citation

Available at

Related Resources From the Same Author(s)

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

April 11, 2012

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

January 11, 2006

Clinical oversight: conceptualizing the relationship between supervision and safety.

July 25, 2007

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative.

August 2, 2023

Factors influencing perioperative nurses' error reporting preferences.

March 28, 2007

Silence, power and communication in the operating room.

June 17, 2009

On the ball: leadership for patient safety and learning in critical care.

August 12, 2009

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.

January 23, 2008

Understanding middle managers' influence in implementing patient safety culture.

September 13, 2017

Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice.

June 8, 2011

Reconceptualizing patient safety beyond harm: insights from a mixed-methods qualitative inquiry.

January 24, 2024

Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact.

April 19, 2023

Allowing failure for educational purposes in postgraduate clinical training: a narrative review.

July 24, 2019

Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions.

October 3, 2012

Piece of my mind. Stories doctors tell.

July 19, 2017

Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children.

August 26, 2009

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.

January 3, 2007

Near misses: paradoxical realities in everyday clinical practice.

February 11, 2009

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

June 21, 2017

Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.

February 8, 2023

Interprofessional communication and medical error: a reframing of research questions and approaches.

October 29, 2008

Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.

December 19, 2007

Resident hesitation in the operating room: does uncertainty equal incompetence?

November 21, 2018

Trainees' perceptions of being allowed to fail in clinical training: a sense-making model.

December 14, 2022

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

November 24, 2021

'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.

November 20, 2019

Slowing down to stay out of trouble in the operating room: remaining attentive in automaticity.

December 8, 2010

The incidence of adverse events among home care patients.

January 30, 2013

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

August 28, 2013

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

June 14, 2006

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

March 18, 2015

Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study.

November 26, 2014

Development of a measure of patient safety event learning responses.

September 23, 2009

Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two Canadian adverse event studies.

June 28, 2017

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

April 14, 2010

Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.

September 4, 2013

How well do we communicate? A comparison of intraoperative diagnoses listed in pathology reports and operative notes.

February 5, 2014

The effect of an organizational network for patient safety on safety event reporting.

August 28, 2013

Assessing adverse events among home care clients in three Canadian provinces using chart review.

November 27, 2013

The sensitivity of adverse event cost estimates to diagnostic coding error.

December 7, 2011

Identification of serious and reportable events in home care: a Delphi survey to develop consensus.

March 5, 2014

Organizational learning in the morbidity and mortality conference.

March 27, 2024

Patient safety in the NICU: a comprehensive review.

July 6, 2011

Impact of nursing on hospital patient mortality: a focused review and related policy implications.

February 22, 2006

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.

January 16, 2008

Communication failures in the operating room: an observational classification of recurrent types and effects.

March 6, 2005

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

February 29, 2012

The costs of developing, implementing, and operating a safety learning system in community practice.

December 11, 2013

Farewell to a cancer that never was.

May 31, 2017

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

October 19, 2005

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

June 22, 2022

Quantifying discharge medication reconciliation errors at 2 pediatric hospitals.

October 27, 2021

Engaging patients to improve quality of care: a systematic review.

November 7, 2018

The pursuit of better diagnostic performance: a human factors perspective.

June 19, 2013

Description of the development and validation of the Canadian Paediatric Trigger Tool.

January 30, 2005

Development of a checklist of safe discharge practices for hospital patients.

April 24, 2013

Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward.

March 18, 2015

Health care governance for quality and safety: the new agenda.

June 20, 2007

Practice makes perfect: planning considerations for medical simulation centers.

December 5, 2012

Patient safety outcomes: the importance of understanding the organizational culture and safety climate.

October 26, 2011

'Cyberloafing' in health care: a real risk to patient safety.

September 5, 2018

Taking bullying out of health care: a patient safety imperative.

January 10, 2018

Aviation tools to improve patient safety.

December 17, 2014

Health literacy and its influence on patient safety.

June 20, 2007

Building accountability through patient safety organizations.

November 21, 2007

Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010.

January 25, 2017

Medication dosing errors for patients with renal insufficiency in ambulatory care.

September 14, 2005

A salutary tale of mistaken identity in testicular cancer.

September 27, 2006

The psychological experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing.

September 2, 2020

Bedside shift report improves patient safety and nurse accountability.

July 28, 2010

The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review.

July 15, 2015

Case-based learning for patient safety: the Lessons Learnt program for UK junior doctors.

March 29, 2012

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

March 6, 2005

Burnout in the NICU setting and its relation to safety culture.

May 7, 2014

Attitudes and opinions of doctors of chiropractic specializing in pediatric care toward patient safety: a cross-sectional survey.

October 19, 2016

Barriers to implementing a reporting and learning patient safety system: pediatric chiropractic perspective.

October 28, 2015

Patient safety: learning from the aviation industry.

January 24, 2007

Frequency of prescribing errors by medical residents in various training programs.

June 10, 2015

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.

June 1, 2022

Association of resident fatigue and distress with perceived medical errors.

September 30, 2009

Finding blunders in thyroid testing: experience in newborns.

July 30, 2008

Intentionally harmful violations and patient safety: the example of Harold Shipman.

July 1, 2009

Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.

June 22, 2011

Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.

January 13, 2016

Beyond 'find and fix': improving quality and safety through resilient healthcare systems.

April 15, 2020

Using incident reporting to improve patient safety: a conceptual model.

March 28, 2007

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

May 17, 2017

Health literacy and mortality among elderly persons.

August 8, 2007

Improving the communication between teams managing boarded patients on a surgical specialty ward.

August 31, 2016

Improving patient safety by understanding past experiences in day surgery and PACU.

June 24, 2009

Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians.

April 1, 2009

Implementation of computerized physician order entry in seven countries.

March 25, 2009

Considering the safety and quality of artificial intelligence in health care.

September 16, 2020

The key to CPOE.

December 12, 2007

Systematic review of the impact of physician implicit racial bias on clinical decision making.

May 5, 2017

Impact of organizational leadership on physician burnout and satisfaction.

February 3, 2016

Patient safety: moving the bar in prison health care standards.

October 13, 2010

Health care providers’ negative implicit attitudes and stereotypes of American Indians.

March 31, 2021

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

March 6, 2005

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Primers

Adverse Events, Near Misses, and Errors

September 7, 2019

Developing a reporting culture: learning from close calls and hazardous conditions.

December 19, 2018

Safety culture includes "good catches."

September 30, 2015

Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric?

August 5, 2015

An analysis of near misses identified by anesthesia providers in the intensive care unit.

July 15, 2015

How can we improve the recognition, reporting and resolution of medical device-related incidents in hospitals? A qualitative study of physicians and registered nurses.

July 8, 2015

Characterising 'near miss' events in complex laparoscopic surgery through video analysis.

May 27, 2015

Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism and a current formal reporting system.

March 18, 2015

Early warnings, weak signals and learning from healthcare disasters.

April 9, 2014

National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations.

March 26, 2014

Medication administration errors in hospitals—challenges and recommendations for their measurement.

March 26, 2014

Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto.

March 12, 2014

Medication errors in hospitalised children.

March 12, 2014

National trends in patient safety for four common conditions, 2005–2011.

January 29, 2014

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.

January 22, 2014

Suffering in silence: a qualitative study of second victims of adverse events.

November 27, 2013

Economic evaluation of the impact of medication errors reported by US clinical pharmacists.

November 27, 2013

Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study.

November 20, 2013

Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization.

November 20, 2013

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study).

November 6, 2013

Compensation of chief executive officers at nonprofit US hospitals.

October 30, 2013

Beyond crisis resource management: new frontiers in human factors training for acute care medicine.

October 30, 2013

Approval and perceived impact of duty hour regulations: survey of pediatric program directors.

October 23, 2013

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.

October 16, 2013

The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study.

October 2, 2013

"That was a close call": endorsing a broad definition of near misses in health care.

October 2, 2013

Detection of medication-related problems in hospital practice: a review.

October 2, 2013

Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?

September 25, 2013

Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.

September 4, 2013

See More About The Topic

Hospitals

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Near Miss

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

Adverse Events, Near Misses, and Errors

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

Adverse Events, Near Misses, and Errors

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site