Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

Palak Kundu; Olivia S Jung; Luca F Valle; Amy C Edmondson; Nzhde Agazaryan; John Hegde; Michael B. Steinberg; Ann Raldow

Study

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

December 16, 2020

Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11(3):e256-e262.

View more articles from the same authors.

Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.

PubMed citation

Available at

Related Resources From the Same Author(s)

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

A blinded, prospective study of error detection during physician chart rounds in radiation oncology.

October 14, 2020

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

March 17, 2021

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists.

August 7, 2013

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

June 30, 2021

Evaluating incident learning systems and safety culture in two radiation oncology departments.

February 16, 2022

Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy.

July 29, 2020

The challenges and opportunities for shared decision making highlighted by COVID-19.

August 12, 2020

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

August 19, 2020

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Planning for a pandemic: mitigating risk to radiation therapy service delivery in the COVID-19 era.

July 22, 2020

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

May 4, 2022

Comparing the evolution of risk culture in radiation oncology, aviation, and nuclear power.

December 9, 2020

Use of therapeutic outcomes monitoring method for performing of pharmaceutical care in oncology patients.

April 28, 2021

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Twelve-month review of infusion pump near-miss medication and dose selection errors and user-initiated "good save" corrections: retrospective study.

November 4, 2020

System factors affecting patient safety in the OR: an analysis of safety threats and resiliency.

August 25, 2021

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

Artificial intelligence versus clinicians: systematic review of design, reporting standards, and claims of deep learning studies.

May 13, 2020

Six major steps to make investigations of suicide valuable for learning and prevention.

November 2, 2022

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

Errors in adult trauma resuscitation: a systematic review.

June 30, 2021

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice.

November 3, 2021

Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to the coronavirus disease 2019 pandemic.

October 21, 2020

Impact of the COVID-19 pandemic on cancer care: a global collaborative study.

November 11, 2020

Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic.

October 7, 2020

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

October 27, 2021

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction.

October 21, 2020

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.

November 11, 2020

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Near miss research in the healthcare system: a scoping review.

May 25, 2022

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic.

October 26, 2022

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system.

September 9, 2020

Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization.

February 12, 2020

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.

March 3, 2021

Sensemaking and learning during the Covid-19 pandemic: a complex adaptive systems perspective on policy decision-making.

September 16, 2020

Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals.

October 14, 2020

Why July matters.

May 11, 2016

COVID-19: an emerging threat to antibiotic stewardship in the emergency department.

October 21, 2020

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

June 23, 2021

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

October 7, 2020

Allergy safety events in healthcare: development and application of a classification schema based on retrospective review.

June 15, 2022

Safety considerations for IMRT.

August 10, 2011

Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic.

November 25, 2020

Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange.

December 23, 2020

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Quality of life after maternal near miss: a systematic review.

June 2, 2021

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

October 21, 2020

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses.

April 14, 2021

Catheter-associated urinary tract infection reduction in a pediatric safety engagement network.

September 30, 2020

Maternal mortality: near-miss events in middle-income countries, a systematic review.

November 24, 2021

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

May 19, 2021

Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning.

December 19, 2012

Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation.

September 16, 2020

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

March 24, 2021

The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.

September 22, 2021

Intraoperative deaths: who, why, and can we prevent them?

March 9, 2022

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

March 8, 2023

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

August 11, 2021

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.

December 2, 2020

Opioid prescribing to US children and young adults in 2019.

September 1, 2021

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

November 17, 2021

Association of surgeon-patient sex concordance with postoperative outcomes,

December 22, 2021

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

August 18, 2021

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

March 11, 2020

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.

July 15, 2020

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

January 25, 2023

Medication reconciliation in ambulatory oncology.

December 5, 2007

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

Serious experience events: applying patient safety concepts to improve patient experience.

July 6, 2022

Related Resources

Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical interactions, treatment, and outcomes.

April 24, 2024

Journal Article

Study

Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.

April 10, 2024

Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care.

March 27, 2024

Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system.

January 24, 2024

Uncovering the risks of anticancer therapy through incident report analysis using a newly developed medical oncology incident taxonomy.

December 13, 2023

What causes delays in diagnosing blood cancers? A rapid review of the evidence.

July 5, 2023

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Influencing a culture of quality and safety through huddles.

November 9, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Factors impacting on patient setup analysis and error management during breast cancer radiotherapy.

November 9, 2022

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

November 2, 2022

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family.

June 1, 2022

Evaluating incident learning systems and safety culture in two radiation oncology departments.

February 16, 2022

Encouraging patients to speak up about problems in cancer care.

January 12, 2022

Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

January 12, 2022

Maternal mortality: near-miss events in middle-income countries, a systematic review.

November 24, 2021

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

July 28, 2021

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

June 30, 2021

Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.

June 7, 2021 - June 8, 2021

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1).

May 5, 2021

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals.

March 31, 2021

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy.

March 24, 2021

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

March 17, 2021

Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome.

December 23, 2020

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.

December 16, 2020

See More About The Topic

Ambulatory Clinic or Office

Quality and Safety Professionals

Hematology

Medical Oncology

Medical Complications

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.

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