Analysis and Process Development to Group Similar Near Miss Data

Background: Patient safety has been a major healthcare concern since the late 1990's when the Institute of Medicine (now known as the National Academy of Medicine) published To Err is Human. The report stated that experts estimate that medical errors account for roughly 98,000 deaths each year in hospitals (Kohn et al, 2000). Since then, many healthcare organizations have developed and implemented interventions and programs with the aim of improving patient safety, however, there is still great challenge with safety event reporting and the ability to analyze the data to determine areas for improvement. Methods: A quality improvement project was developed to review and analyze near-miss events to determine areas of focus to improve patient safety. The focus of the near-miss events was those related to communication. The data were initially reviewed and placed into similar, broad categories. The data was then reviewed a second and third time and placed into more defined categories, primarily indicating where or between whom the lack of communication or miscommunication took place. The top 12 categories were then provided to the patient safety team to determine the effectiveness of the process and where there may be actionable areas to improve. Results: The majority of the near miss events were related to miscommunication or lack of communication between team members, the highest being between non-clinical caregivers. There was a small number of reports related to conflict in communication. Conclusions: Qualitative content analysis was helpful to determine areas of focus to improve patient safety. Given it is a manual process it would provide greater benefit if the categories were built into the reporting system. Replication of this quality improvement project also needs to be completed in a different general event type to determine if this process would work for all general event types.