Presentation

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Ignorance is Not Bliss: Addressing Near Miss and Precursor Safety Concerns

DescriptionThe modern patient safety movement began 25 years ago. Despite a quarter century of work to reduce preventable harm and improve patient safety, adverse patient safety events remain prevalent, with an estimated one out of every four patients experiencing preventable harm (Bates et al., 2023). There is no singular reason for the lack of greater progress. Healthcare is a complex industry that continues to evolve, continuously adding new layers of intricacy, thus compounding an already difficult process of determining what happened and why when there is an adverse patient event. However, one potential contributing factor to the slow progress may be the blanket approach leveraged by most healthcare organizations to analyze patient safety events. To date, Root Cause Analysis (RCA) remains the predominant method to analyze avoidable harm; yet more and more safety professionals are challenging this approach and calling attention to the multitude of limitations of the RCA (Peerally et al., 2017). Peerally and colleagues noted the focus on single, severe event investigations, which is the typical method leveraged by healthcare organizations, limits the ability to dedicate resources to less severe, but more numerous events, that if addressed could have wider spread positive ramifications on overall patient safety.

We previously proposed and presented an aggregated event analysis approach, rooted in human factors system’s thinking (Anderson-Montoya, et al., 2024). The method classifies patient safety concerns to identify trends that can then be elevated for deeper system safety evaluations. This approach classifies any potential patient safety concern, whether or not there was a direct impact to the patient, which calls attention to near miss and precursor safety events. Therefore, rather than investigating these events only when they unfortunately, and inevitably, become a severe safety event, we are offering an approach that does not ignore the red warning signs but rather focuses on these events for performing evaluations to proactively mitigate more severe events from occurring.
We will present the results of using this aggregated approach for telemedicine patient safety event analysis, highlighting how Safety Concern Classifications can be used to classify any potential patient safety concerns to then identify trends to be elevated for aggregate adverse event investigation. We will also discuss how this approach can be leveraged in brick-and-mortar settings, and how this approach can compliment the more traditional single event investigation process.

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