Strategies to increase reporting of near misses and adverse events.

Caroline Conerly

Commentary

Strategies to increase reporting of near misses and adverse events.

March 28, 2007

Conerly C. J Nurs Care Qual. 2007;22(2):102-6.

View more articles from the same authors.

The author describes one hospital's campaign to encourage reporting of near misses and adverse events by acknowledging staff for reporting such events.

PubMed citation

Available at

Related Resources From the Same Author(s)

Flaws in clinical reasoning: a common cause of diagnostic error.

January 11, 2012

Medication governance: preventing errors and promoting patient safety.

March 15, 2017

Common and consequential fractures that should not be missed in children.

November 30, 2022

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

February 1, 2023

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis.

April 29, 2015

Adjusting to duty hour reforms: residents' perception of the safety climate in interdisciplinary night-float rotations.

February 20, 2019

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.

February 25, 2015

Are apologies a way to reduce malpractice risks?.

June 21, 2023

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.

August 12, 2020

Cognitive bias and dissonance in surgical practice: a narrative review.

April 26, 2023

The simulated ward: ideal for training clinical clerks in an era of patient safety.

May 9, 2012

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

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

November 11, 2020

Promoting patient safety using an early warning scoring system.

August 27, 2008

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

December 17, 2014

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.

August 24, 2022

Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review.

March 23, 2022

Impact of a computerized physician order entry system on compliance with prescription accuracy requirements.

August 5, 2009

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

January 13, 2016

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.

January 27, 2016

Association of face-to-face handoffs and outcomes of hospitalized internal medicine patients.

April 29, 2015

A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training.

September 2, 2015

Culture of safety: impact on improvement in infection prevention process and outcomes.

February 3, 2021

Adaptation and implementation of the WHO Safe Childbirth Checklist around the world.

November 3, 2021

Missed nursing care during the COVID-19 pandemic: a comparative observational study.

July 21, 2021

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study.

June 22, 2022

Error codes at autopsy to study potential biases in diagnostic error.

January 10, 2024

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis.

January 26, 2022

Patient safety: do nursing and medical curricula address this theme?

June 1, 2005

Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center.

March 30, 2016

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.

August 30, 2023

Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.

October 9, 2019

March 11, 2020

Improving general practice computer systems for patient safety: qualitative study of key stakeholders.

February 28, 2007

Impact of Medicare's nonpayment program on hospital-acquired conditions.

January 11, 2017

An adverse event screening tool based on routinely collected hospital-acquired diagnoses.

May 30, 2012

Emergency department checklist: an innovation to improve safety in emergency care.

October 31, 2018

Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.

July 26, 2017

Creating a stronger culture of safety within US community pharmacies.

April 12, 2023

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

July 15, 2009

Impact of individual and team features of patient safety climate: a survey in family practices.

August 14, 2013

Mortality due to hospital-acquired infection after cardiac surgery.

June 1, 2022

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.

January 2, 2008

Guided prescription of psychotropic medications for geriatric inpatients.

May 18, 2005

Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes.

April 22, 2015

Strategies for improving patient safety culture in hospitals: a systematic review.

August 15, 2012

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

March 17, 2021

Learning from litigation. The role of claims analysis in patient safety.

December 13, 2006

Medication reconciliation in a community pharmacy setting.

August 11, 2010

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

May 12, 2010

Blame the patient, blame the doctor or blame the system? A meta-synthesis of qualitative studies of patient safety in primary care.

August 26, 2015

Patient safety issues in advanced practice nursing students' care settings.

November 9, 2011

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

April 7, 2021

How might health services capture patient-reported safety concerns in a hospital setting? An exploratory pilot study of three mechanisms.

April 20, 2016

Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses.

April 26, 2017

Cognitive bias impact on management of postoperative complications, medical error, and standard of care.

November 4, 2020

Structural racism in behavioral health presentation and management.

May 17, 2023

Differences in day and night shift clinical performance in anesthesiology.

June 4, 2008

Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention.

January 24, 2018

Time of day and the decision to prescribe antibiotics.

October 22, 2014

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews.

May 14, 2014

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings.

May 6, 2009

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

September 7, 2022

Communication disparities between nursing home team members.

July 20, 2022

What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study.

March 28, 2018

Impact of fatigue on anaesthesia providers: a scoping review.

June 14, 2023

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

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

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.

March 2, 2022

Missing clinical information during primary care visits.

April 3, 2005

Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program.

January 25, 2017

The patient reporting and action for a safe environment (PRASE) intervention: a feasibility study.

December 21, 2016

Pharmaceutical interventions to improve safety of chemotherapy-treated cancer patients: a cross-sectional study.

February 27, 2019

The physiology of failure: identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

September 7, 2022

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Quality management and perceptions of teamwork and safety climate in European hospitals.

January 20, 2016

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes.

June 6, 2018

Association of inappropriate outpatient pediatric antibiotic prescriptions with adverse drug events and health care expenditures.

June 8, 2022

Are physician assistants able to correctly identify prescribing errors? A cross-sectional study.

September 20, 2023

Patient safety in marginalised groups: a narrative scoping review

March 4, 2020

Drug administration errors and their determinants in pediatric in-patients.

September 7, 2005

Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.

February 15, 2017

Measurement for improvement: a survey of current practice in Australian public hospitals.

July 23, 2008

Antibiotic prescribing practice in residential aged care facilities—health care providers' perspectives.

August 20, 2014

Overdiagnosis in low-dose computed tomography screening for lung cancer.

December 18, 2013

Influence of burnout on patient safety: systematic review and meta-analysis.

October 23, 2019

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial.

November 8, 2017

Patient safety in palliative care at the end of life from the perspective of complex thinking.

August 16, 2023

Patient perspectives on the use of artificial intelligence for skin cancer screening: a qualitative study.

April 1, 2020

Incidence and outcomes of non-ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria.

June 7, 2023

Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis.

June 26, 2019

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

March 7, 2012

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.

June 22, 2016

Association of postoperative readmissions with surgical quality using a Delphi consensus process to identify relevant diagnosis codes.

May 16, 2018

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review.

December 8, 2021

Nurse Staffing Levels, Missed Vital Signs and Mortality in Hospitals: Retrospective Longitudinal Observational Study.

December 19, 2018

Evidence-based organization and patient safety strategies in European hospitals.

March 19, 2014

How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.

January 11, 2023

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

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

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

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

June 23, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.

July 29, 2020

Impact of an electronic health record transition on chemotherapy error reporting.

June 17, 2020

Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States.

May 13, 2020

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

April 1, 2020

The influence of organizational culture, climate and commitment on speaking up about medical errors.

December 18, 2019

Detecting medication administration errors.

September 18, 2019

The courage to speak out: a study describing nurses' attitudes to report unsafe practices in patient care.

August 14, 2019

Intentional rounding—an integrative literature review.

August 7, 2019

The attitudes of nursing students and clinical instructors towards reporting irregular incidents in the medical clinic.

June 5, 2019

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Targeting the fear of safety reporting on a unit level.

March 20, 2019

Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department.

February 27, 2019

Using good catches to promote a just culture and perioperative patient safety.

December 12, 2018

Blame: what does it look like?

November 14, 2018

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

Exploring how nursing schools handle student errors and near misses.

December 13, 2017

Reporting medication errors: residents with diabetes.

November 26, 2014

Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes.

October 29, 2014

Creating a distraction simulation for safe medication administration.

September 3, 2014

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.

August 27, 2014

Weaving a healthcare tapestry of safety and communication.

July 16, 2014

Developing a reporting and tracking tool for nursing student errors and near misses.

May 28, 2014

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

May 14, 2014

See More About The Topic

Hospitals

Nurses

Nurse Managers

Quality and Safety Professionals

Epidemiology of Errors and Adverse Events

Strategies to increase reporting of near misses and adverse events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Strategies to increase reporting of near misses and adverse events.

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