Causes of Near Misses: Perceptions of Perioperative Nurses

Cohoon, Barbara D.

Friday, 3 August 2012: 9:10 AM

Barbara D. Cohoon, PhD, MSN, RN
Department of Government Relations, National Military Family Association, Alexandria, VA

Learning Objective 1: The learner will be able to recognize near misses and understand the perception of the cause of near misses.

Learning Objective 2: The learner will be able to identify categories of near miss causes and their frequency.

Purpose: The purpose of this study was to examine the near miss experiences of Registered Nurses working in perioperative settings at a multi-facility health system in the Mid-Atlantic region of the United States to determine if near misses might be an early warning system, and their detection a source of impending system failures before errors result.

Methods: The framework for this study was van Vuuren’s 1998 modified version of the Simple Model of Incident Causation created by van der Schaaf in 1992. This model explained the causes of near misses. The study design used quantitative and qualitative analysis. It was descriptive, using a Survey of Perioperative Nurses developed for the study.

Results: Participants ranked six causal factors according to the factor(s) contributing to the near miss. Team factor was identified the most as a contributing factor by participants. Findings provided information on the frequency and types of near miss causes experienced by Perioperative Nurses.

Conclusion: Results contributed to the health care system’s safety/quality system. The study’s findings helped gain an understanding of Perioperative Nurses’ near

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