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BMJ Qual Saf doi:10.1136/bmjqs-2011-000256
  • Original research

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes

  1. G Ross Baker4
  1. 1Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
  2. 2Early Nursing Research Career Award, Ministry of Health and Long Term Care (Ontario)
  3. 3Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
  4. 4Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  5. 5Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
  6. 6Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
  1. Correspondence to Dr Lianne Jeffs, Director of Nursing/Clinical Research, Scientist, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Early Nursing Research Career Award, Ministry of Health and Long Term Care, 5-060 Bond Wing, 30 Bond Street, Toronto, ON M5B 1W8, Canada; jeffsl{at}smh.ca
  1. Contributors LJ, the principal investigator, made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data, drafted the article and revised it critically for important intellectual content and provided final approval of the version to be published. WB, LL and GRB also contributed to the conception, design, analysis and interpretation of data, revision of the article critically for important intellectual content and provided final approval of the version to be published.

  • Accepted 15 December 2011
  • Published Online First 22 February 2012

Abstract

Introduction The extent to which individuals in healthcare use near misses as learning opportunities remains poorly understood. Thus, an exploratory study was conducted to gain insight into the nature of, and contributing factors to, organisational learning from near misses in clinical practice.

Methods A constructivist grounded theory approach was employed which included semi-structured interviews with 24 participants (16 clinicians and 8 administrators) from a large teaching hospital in Canada.

Results This study revealed three scenarios for the responses to near misses, the most common involved ‘doing a quick fix’ where clinicians recognised and corrected an error with no further action. The second scenario consisted of reporting near misses but not hearing back from management, which some participants characterised as ‘going into a black hole’. The third scenario was ‘closing off the Swiss-cheese holes’, in which a reported near miss generated corrective action at an organisational level. Explanations for ‘doing a quick fix’ included the pervasiveness of near misses that cause no harm and fear associated with reporting the near miss. ‘Going into a black hole’ reflected managers' focus on operational duties and events that harmed patients. ‘Closing off the Swiss-cheese holes’ occurred when managers perceived substantial potential for harm and preventability. Where learning was perceived to occur, leaders played a pivotal role in encouraging near-miss reporting.

Conclusion To optimise learning, organisations will need to determine which near misses are appropriate to be responded to as ‘quick fixes’ and which ones require further action at the unit and corporate levels.

Footnotes

  • Learning from near misses most often is manifested in practice by the individual clinician who does a quick fix or reports near misses that then go into a black hole with no organisational learning taking place. In some cases, reported near misses result in organisational learning and thereby corrective actions that close off the Swiss-cheese holes.

  • Funding This study was partially funded through a University of Toronto and Canadian Institutes of Health Research Interdisciplinary Capacity Enhancement Knowledge Translation in Patient Safety Doctoral Scholarship.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by University of Toronto and The Hospital for Sick Children research ethics boards.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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