Paper
Saturday, July 24, 2004
This presentation is part of : Perceptions of Quality
Near Misses: Health Professionals' and Consumers' Perspectives
Dyanne Affonso, RN, PhD, Nursing, University of Toronto, Toronto, ON, Canada and Lianne Jeffs, RN, MN, Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
Learning Objective #1: Understand collaborative partnerships in knowledge generation, transfer, and uptake on patient safety/near misses
Learning Objective #2: Understand lessons learned from near misses to improve patient safety practices
Near Misses: Health Professionals and Consumers Perspectives Nursing is called to move patient safety beyond errors and risks through a broader perspective of the complexities in the processes of care that is fundamental to safer health care systems. Clinical practice is besieged by "near miss incidents", captured by nurses because of 24/7 vigilance in patient care. Near misses hold promise for understanding errors and designing better systems to avoid them.

Concepts/Variables: There is lack of consensus about what are near misses and no conceptual underpinnings for a working definition to guide research and clinical practice. Meanings and context of near misses have yet to be documented.

Objective: Results of a study that explored near misses in selected patient care settings will be presented relative to staff perceptions and processes of care associated with their occurrence.

Design/Methods/Population/Sample/Setting/Years: Focus group methods will be used to describe near misses from a consumer and health care team perspective. Perceptions among nurses, pharmacists and patients/families regarding what constitutes near miss, safe processes, and desired outcomes will be elicited. Content analysis includes coding, categories, and thematic analysis.

Findings: Divergent views of the meanings and context of near misses will be presented.

Implications: Knowledge of the nature and characteristics of near misses, including indicators for measurements will be new databases to inform further inquiry.

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Sigma Theta Tau International
July 22-24, 2004