Self-Reporting Systems Improve Patient Safety

Picture a Registered Nurse working in a busy oncology unit. While actively trying to juggle being an attentive medical professional as well as a fast and thorough one, she meets with patients to offer a sense of comfort and capability. She goes to assess a patient and realizes that her bag of morphine, which is used in the patient’s patient-controlled analgesia (PCA) system, is nearly empty.

The nurse goes to the automated dispensary cabinet in order to retrieve a new bag. As she walks out of the medication room, bag in hand, the nurse finds a colleague to meet her in her patient’s room in order to double-check the PCA.

Upon going back to the patient’s room, the nurse puts the bag down to a fix the patient’s compression stockings. Her colleague comes into the room and tells her to perform the double-check right away, before even traveling with her patient. This distraction has allowed her to refocus, but then notices that the medication she left on the table was not morphine, but fentanyl, which is 50 to 100 times stronger than morphine and 30 to 50 times as potent as heroin.

While the mistake was not actually made, these near misses happen all the time. Remember, everyone makes mistakes at work. Unfortunately for medical professionals, a minor slip up doesn’t just mean handing in late paperwork - it could mean the loss of a life. While thankfully no one was hurt in that scenario, someone very easily could have been, so why are there so many near misses? And what can be done about them? 

Near-miss events are actually more common than real accidents

That scenario is an example of a near-miss event, but it is also something that could have gone horribly wrong and resulted in death. Though it was corrected before it was an issue, the cold truth is that the only significant difference between a near-miss event and an actual event is the end result.

According to studies, near-miss events happen anywhere from three to 300 times more frequently than actual adverse events as a result of negligence. These statistics have lent themselves nicely to quantitative research and analysis. These cases can and should be studied in hopes that reviewing the incident will point to changes that can be made in the healthcare system or help the system prepare to respond in a proactive and meaningful way. These near-miss events need to be reported in a system that allows for the people reporting them to remain anonymous.