Quality Improvement in Health Care (한국의료질향상학회지)

Korean Society for Quality in Health Care (한국의료질향상학회)
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Near Misses Experienced at a University Hospital in Korea

  • Park, Mi-Hyang (Department of Public Health, The Graduate School of Konyang University) ;
  • Kim, Hyun-Joo (Department of Nursing Science, Shinsung University) ;
  • Lee, Bo-Woo (Department of Public Health, The Graduate School of Konyang University) ;
  • Bae, Seok-Hwan (Department of Radiological Science, College of Medical Science, Konyang University) ;
  • Lee, Jin-Yong (Public Health Medical Service, Boramae Medical Center, Seoul National University College of Medicine)
  • Received : 2016.03.04
  • Accepted : 2016.06.06
  • Published : 2016.06.30
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Abstract

Objectives: This study aimed to investigate how many healthcare professionals experienced near misses, what types of near misses occurred most often, and healthcare professionals' opinions about near misses at one university hospital in Korea. Methods: The authors developed a questionnaire including 26 core types of near misses and 4 questions about preventability and reporting barriers. The survey was conducted from Oct. 31st to Nov. 18th 2011, about 3 weeks, using a self-administrated questionnaire that was administered to 697 healthcare professionals (registered nurses, pharmacists, technicians, and nurses aides) who worked at a university hospital. Medical doctors and employees working in the department of administration were excluded. Results: About half of hospital workers experienced at least one or more near misses during the past one year. The drug dispensing process was the most common subcategory of near misses. Among the 26 items, patient falls was highest. Over 95% of respondents reported that the near miss they experienced was preventable. Also, more than half of respondents did not report the near miss and the main reason for omission was fear of blame. Conclusion: Regarding patient safety issues, a near miss is a very significant factor because it can be a potential adverse event. Therefore, we should grasp the size of the problem through tracking and analyzing near misses and should make an effort to reduce them. To do so, we should check whether our reporting system is well designed and functioning.

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References

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