Near Miss Events

[DFields]

Please share how your facility decides if events are "near miss"?

If caught prior to distribution (such as at the issue window) and this is part of your process, do you consider that a near miss?

Processing errors, if caught prior to distribution, would they be "near miss" events?

[John C. Staley]

Here's one that I considered a "direct hit" but the hospital risk manager chose to call a "near miss" using JCAHO's guidelines. By the "no harm done" definition quoted from AABB I did not have much of an argument.

Two units of RBCs were sent to ICU minutes apart in the pneumatic tube system. They ended up switched and going to the wrong room. Nursing had mutated the bedside pre-transfusion process and both units were transfused to the wrong patient. I was notified when it was discovered as they were posting the bagtags in the chart.

Here's the "near miss" part: both patients were A pos, both units were A pos, neither patient had atypical antibodies and upon subsequent crossmatching both were found to be compatible with they patient they ended up in. NO HARM DONE!!! High level nursing tried to sweep it under the rug by beating up a couple of ICU nurses and calling it good. I insisted upon a true root cause analysis. We discovered the problem. The bedside, pretransfusion checks were better outlined in the nursing manual and education was commenced hospital wide. (A little more involved but my fingers are getting tired.)

I still contend that this was not a "near miss"! It was a direct hit, we were just extremely lucky that no one was harmed. In my view a near miss is something that is caught somewhere along the process as it should be thereby stopping the process until it is corrected.

[tbostock]

You're right, John, that was a hit, not a miss. I agree that a miss is something you catch before it reaches the patient.

Our latest near miss here: When we were doing a blood type verification on a new patient inhouse, it didn't match his original specimen drawn that day by the nurse on that floor. Found out upon questioning that she really collected the blood from his roommate, put the blank tube in her pocket and went to the desk. Then she was asked "a million questions" by doctors, unit secretaries, etc, until she got distracted. When she finally remembered to label the tube, she grabbed the wrong addressograph card (the roommates). Our policy is to handlabel the tube at bedside directly from the wristband....she was an experienced nurse who knew the policy but chose to do it her way.

This was a near miss because we had a process to catch that error before blood reached the patient's bedside. Thank God we had just implemented the blood type verification process a few months prior...or it would have been a direct hit.

[Likewine99]

John, you are right it's a direct hit.

The patient received blood that was not intended for them, even though the ABO/Rh was correct and the absc neg, what about exposure to antigens in the donor units and the risk of a tx transmitted disease?

[Eagle Eye]

JOhn you are right, it was no harm event..but not near miss.

I think this is reportable to FDA under new BPD form? NO Here transfusion service issued correct product and mixed up was on teh floor..

Edited December 8, 2008 by aakupaku
changed the comment/2nd line

[rescyth]

wow! talk about luck... i think a good way to describe a "near miss" is like this...

Near miss = wow almost transfuse the wrong patient, glad i caught it on time.

but your situation is like this... "wow, we've already transfused it to the wrong patient" !

well that's just my 2 cents here.

[n.peters]

I also can not believe it was considered a near-miss. To me if it happened and was not caught it should be treated like worst case because it was just by chance it was not, it still happened. Luckily it did not hurt that particular patient but what difference does that really make if it could happen again.

[whbb]

Our hospital is AABB. In the last two previous surveys, it was ALWAYS a nursing error that gave the BB an infraction.

Why is the BB so heavily inspected and nursing is not held accountable?