How can reporting near-misses prevent harm and improve outcomes?
Particularly near-miss refers to an unplanned event, which did not lead to sickness, injury or damage even though it had the potential to do so. Basically, the event was about to happen, but fortunately, a break in the chain of events prevented its occurrence, in other words, a near-miss is a miss that was nonetheless near (Crane et al., 2015). Majorly the cause of a near miss is a faulty process or management system.
Reporting near misses helps in the prevention of future harm related instances and improve outcomes in the following ways:
First and foremost, with a well-established reporting culture which eventually communicates that every opportunity that a hazard is identified and controlled contributes positively towards reducing the risk and preventing harm-related events from happening. However, the reporting culture or system need to be non-punitive and maintain privacy and confidentiality of the person reporting the near miss event (Crane et al., 2015). Also, reporting near misses provides an avenue for investigations to be done with an aim of identifying the root cause and weaknesses that lead to the event. This helps in coming up with strategies for preventing the real event from taking place in future (Manchikanti et al., 2013).
Furthermore, reporting of near misses helps in improvement of processes and management systems. Results obtained from the investigation of a reported near-miss event is used in the development of safety systems, hazard control, and reduction of risk and contributes to learning a lesson (Manchikanti et al., 2013). Even though medical practitioners shy away from reporting cases of near misses, it is paramount since it prevents severe, fatal and catastrophic incidences which are less frequent but more harmful when they occur than other incidents (Manchikanti et al., 2013).
Explore ways that transformation and the "learning" organization can help to create safer systems
Transformation and the “learning “ organization should implement safer reporting systems which capture sufficient data that will be used for statistical analysis, correlation studies, trending and measuring of performance which is in line with improvement over baseline. Moreover, this organization should encourage employee participation which in this case is the medical practitioners fraternity so as to provide an equal opportunity of coming up with safety solutions (Manchikanti et al., 2013). As a matter of fact, the creation of an open culture where everyone is free to share his or her opinion and experience contributes responsibly to his or her safety and also can be considered as an indication of performance that might be used in line with other measures of performance.
Employers should also create policies and procedure directed to all employees with support from the senior management. In addition, the organization should facilitate employee education on the importance of safer systems (Crane et al., 2015). Also, managers can use this report obtained from the learning experience as a leading indicator and generate an organizational report that can be used as a measure of the steps taken to improve safety in the workplace.
In most cases, health care professionals typically experience devastation and embarrassment about the mistakes that they may be tempted to conceal or shift the blame to someone or something else as a way of defending themselves (Manchikanti et al., 2013). With an effective, ethical framework, medical practitioners may benefit from the action of accepting responsibility for errors, reporting the mistakes and sharing them with the medical fraternity. This not only builds trust, but also creates a safer system which won’t be the case if errors and mistakes were covered. As a matter of fact, the errors and mistakes do not stay hidden, but cause compromising situations as far as the mission of a particular organization is concerned.
References.
Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., & Zimmerman, S. (2015). Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes. The Journal of the American Board of Family Medicine, 28(4), 452-460.
Manchikanti, L., Falco, F. J., Benyamin, R. M., Caraway, D. L., Kaye, A. D., Helm 2nd, S., & Swicegood, J. R. (2013). Assessment of bleeding risk of interventional techniques: a best evidence synthesis of practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Pain physician, 16(2 Suppl), SE261-318.
