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Near Misses: why bother?

Kerry is a veterinary intern who was rostered on an overnight shift in the intensive care unit of a busy emergency referral hospital. One of her tasks was to help administer insulin to a patient who was being treated for a severe type of diabetes. As Kerry was preparing the medication, she realized that the dose written on the patient’s record was much higher than what is normally administered to patients with diabetes. Kerry knew that giving the wrong dose could cause serious harm to the patient, and she immediately stopped what she was doing. Kerry reviewed the medication order and found that her colleague might have made an error when hand writing the order into the patient’s record. Instead of dispensing 10 IU of the medication, the doctor had mistakenly entered 100 IU. Kerry knew that she had to act quickly to prevent the patient from receiving the incorrect dose.


Kerry immediately called and notified the vet responsible for the patient about the possible mistake. The vet acknowledged the mistake and corrected the medication order, and the patient was given the correct dose without any harm. Kerry's quick thinking and willingness to speak up prevented a potential medication error and ensured that the patient received the appropriate treatment. The near miss was documented and reviewed by the hospital's quality improvement team to identify ways to prevent similar errors from occurring in the future. One of the possible solutions Kerry told management to avoid future incidents was for a two-person check when writing medication orders in the patient's record.


 

A near miss is a term used to describe an event in which an accident almost occurs but is avoided at the last moment. It refers to a situation where an object, person, or other hazard comes dangerously close to causing harm, but through a stroke of luck or quick action, the harm is avoided. In other words, it's an event that could have resulted in an accident or injury but did not.


Just like in healthcare and aviation there are also near misses in veterinary medicine. Some examples of near misses are:


1. Dispensing the wrong medication, route, or dosage: This can happen when veterinary staff are rushed, distracted, poor hand writing, or not properly trained. For example, a nurse may pick up the wrong medication from the shelf or misinterpret a dosage on a medication record.


2. Miscommunication between veterinary staff: This can occur between veterinarians, nurses, and other staff, leading to errors in treatment or diagnosis. For example, a veterinarian may request a medication that a patient is allergic to because the allergy information was not communicated effectively.


3. Equipment malfunctions: Equipment such as anaesthesia machine, breathing circuits, and surgical instruments can malfunction causing potential harm to patients. For example, an APL valve was left closed in a previous anaesthetic and a different staff notices the valve closed before connecting the next patient to the breathing system.


4. Incorrect labelling of samples: When samples are collected from patients for laboratory tests, incorrect labelling can occur, leading to incorrect results and potentially inappropriate treatment. For example, a blood sample may be labelled with the wrong patient's name or identification number.


Reporting near misses are important because they help organizations identify and address potential safety hazards before they result in actual accidents or injuries. When a near miss occurs, it indicates that there is a gap in the safety system that needs to be addressed. By reporting the incident and investigating its causes, organizations can identify the underlying issues and take corrective action to prevent similar incidents from happening in the future.


Near miss reports can also be used to improve safety culture within an organization. By encouraging employees to report near misses, organizations create a culture where safety is a top priority and employees feel empowered to speak up when they see potential hazards.


In addition, near miss reports can provide valuable data for safety performance metrics. By tracking the number and type of near misses that occur, organizations can identify trends and patterns that may indicate areas where further safety improvements are needed.


In the author's opinion, close-loop communication plays a critical role in avoiding errors, particularly in high-risk environment, such as the veterinary industry. Close-loop communication is a process that involves verifying and confirming that a message or instruction has been understood and acted upon correctly. This type of communication can help prevent errors by ensuring that information is transmitted accurately and completely, and that the intended actions are taken.


In healthcare, for example, close-loop communication is essential to prevent medication errors, misdiagnosis, and other errors that can have serious consequences for patients. By implementing close-loop communication processes, healthcare providers can ensure that information is communicated accurately and completely, and that patients receive the appropriate care.


Handovers are a critical aspect of patient care, as they involve the transfer of important information about the patient, including their medical history, current status, and ongoing care needs. Effective handovers are essential for maintaining patient safety and preventing adverse events. Poor communication during handover can lead to near misses.


The ISBAR communication tool can be a useful tool for handover and ensuring patient safety. ISBAR stands for Identify, Situation, Background, Assessment, and Recommendation. It is a structured communication tool that is commonly used in healthcare settings to facilitate effective and efficient communication during handover or when discussing patient care. By following the ISBAR format, one can ensure that important information is shared accurately and efficiently, reducing the risk of miscommunication and errors. The tool helps to standardize communication and ensure that all necessary information is covered.


Overall, near miss reports are as important as adverse events for improving safety, preventing accidents, and promoting a strong safety culture within organisations.

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