Dr Nick Woodier, Trent Simulation and Clinical Skills Centre, Nottingham University Hospitals NHS Trust
A doctor, prescribing antibiotics, proceeds to write Tazoscin (a penicillin-based antibiotic) and passes the prescription to the nurse to administer to the patient. The nurse undertakes the routine checks and identifies that the patient has a severe allergy to penicillin. The nurse does not administer the medication.
These types of “almost” cases are not uncommon in healthcare, but we know about very few of them . When they are reported, they are often described as “near misses.” But how can they be a near miss? An event has occurred that could have caused harm to the patient- the prescribing of the antibiotic. If these types of instances were recognised as patient safety incidents, would this not support improved reporting of these grossly underreported events?
The recognised healthcare definition of near misses is provided by the NPSA who define them as: “prevented patient safety incidents;” where an incident is: “…any unintended or unexpected incident (event) which could have or did lead to harm…”.
One contributor toward low rates of near-miss reporting is thought to be the lack of a standardised definition. However, nationally, this standardised definition exists. What is more likely is the difficulty that frontline staff face in applying that definition to their practice. Incident causation is not linear, rather a complex web of pre-cursor hazards, events and errors. The definition of near miss is clear in that it is a “prevented” incident. However, how do you define where that point of prevention occurred when incident causation is so complex?