Study of hospital near misses reveals the important role nurses play

nurse in focus june 10In healthcare settings, a near-miss event is a situation that has the potential to cause injury to a patient but is averted due to timely intervention on the part of staff. Though long overlooked as merely being close calls, near misses are receiving closer examination these days as hospital administrators seek ways to prevent and correct problems before they occur.

Stacen Keating, PhD, RN, assistant professor of nursing at TCNJ, recently completed a qualitative study of near-miss events intercepted by registered nurses at a local hospital. She is still doing a thorough analysis of the data she collected, and intends to publish her findings in a nursing journal. While her published research will undoubtedly help hospitals improve patient care, her preliminary findings are already providing insight into the skills nurses need to be successful and the key role nurses play in patient care.

Keating interviewed 16 RNs who detailed 56 near-miss events they had experienced during their career. She divided these events into categories based on the root cause of the averted errors—for example, lapses in screening requirements, administration of improper medication, and miscommunications between hospital staff and patients.

By far the most common type (60 percent) of near misses Keating documented were assessment related.

“An ‘assessment near miss’ is the perception [on the nurse’s part] that the patients’ physical assessment or presentation warrants additional follow-up, testing, closer monitoring, or interdisciplinary collaboration,” Keating explained.

Such a high incidence of this type of near miss didn’t surprise Keating. “Nurses are uniquely in tune with patients and their physical and mental presentations in the hospital,” she explained. “[They] see the patient the most throughout the day, and any slight change or subtle variation in status seems to raise a red flag for nurses.”

What can be interpreted from Keating’s preliminary findings is how important it is for practicing nurses to be critical thinkers. The assessment-related near misses Keating documented reveal how, in a number of cases, a nurse’s continuous expert monitoring and assessment of a patient prevented harm—and in at least one instance, death—from befalling a patient.

“Often nurses are [mostly] identified with providing certain ‘skilled’ aspects of nursing care [such as] caring for wounds and infections,” Keating said. Doctors, hospital administrators, and even nurses themselves sometimes overlook how essential critical thinking skills can be for a nurse to deliver “high quality and expert patient care,” she explained.

That lesson hasn’t been lost on Veronica Garces, the junior nursing student who is assisting Keating with the study. She says the experience has taught her “how [important] it is for nurses to stay on top things when it comes to patient care,” said Garces. “Doctors aren’t always going to be right, so it’s the responsibility of nurses to…check orders that patients already have to secure their patients’ safety.”

Keating’s interest in examining near misses stems from work she did while a doctoral student at the University of Pennsylvania. There, she worked with a team of economists and nurse researchers to highlight the contributions that nurses make to healthcare.

“Typically you can attribute good or bad results to physicians, and can parse out what a physician has done to effect a patient outcome,” Keating explained. “But because of the collaborative and multidisciplinary nature of healthcare in the hospital, it’s often hard to parse out what is specifically nurse driven, or what contributions nurses make.”

“I kept asking myself, ‘What is the contribution of a nurse, and what is the value of having a nurse as opposed to some other member of the team?’” Keating explained. “And that got me thinking that these near-miss episodes—the things that nurses avoid happening—are indications of critical thinking and what nurses bring to the table to improve quality of care.”

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