Congress Abstracts 2003

25

DON’T WAIT FOR SOMETHING BAD TO HAPPEN TO CHANGE PRACTICE: AVOIDANCE OF SENTINEL EVENTS BY LEARNING FROM NEAR MISSES. Jean Roberson, RN, BSN, Dana-Farber Cancer Institute, Boston, MA.

Background: A major area of concern in healthcare is development and maintenance of patient safety standards. One area of patient safety is “near miss” events. “Near miss” events are errors that do not result in harm. When a near miss occurred on an infusion unit in a comprehensive cancer center, it was used as an opportunity to evaluate and change the unit-based practice standards.

Intervention: The near miss event involved a patient in the process of being discharged when it was discovered that the final chemotherapeutic agent had not been administered. Immediate discovery and correction resulted in no patient harm and transformed it into a learning experience: (1) One of the nurses brought her involvement to the attention of the nurse manager. It was recognized that this event created anxiety and frustration for her and the other staff involved. (2) The group of nurses involved was called together to discuss all of the related details, including identification of contributing factors. (3) The group reviewed current unit practice and discussed possible improvements. (4) Suggestions from the group members to change practice were delineated. (5) At a unit staff meeting, the group presented the incident, contribution factors, and suggestions to change unit practice. (6) The entire staff was invited to share any similar situations that they may have witnessed and their ideas for improving current practice. (7) Changes in unit practice standards were implemented.

Evaluation: After six months, no similar near misses have occurred. Staff provided positive feedback on the processes that took place.

Discussion: Critically reviewing near miss incidents is a valuable tool that can be utilized to improve practice and patient safety at the unit level. Discussion of a near miss event gives everyone the opportunity to critically evaluate systems that are currently in place and the role they play in patient safety. Inclusion of staff in the process enables them to proactively evaluate practice, identify concerns, and make changes that result in quality improvement.