REVIEW ARTICLE
The Value of Learning From Near Misses to Improve Patient
Safety: A Scoping Review
Nick Woodier, BMBS, CErgHF, MSc, Charlotte Burnett, BMedSci, and Iain Moppett, DM
Objectives: For years, health care has recognized that learning from near
misses offers potential opportunities to reduce unintended harm to patients.
However, these benefits have yet to be realized. It is assumed that effective
actions are being implemented as a result of learning from healthcare near
misses, leading to improvements in patient safety. A scoping review of the
healthcare literature was undertaken to explore the value of learning from
near misses in the improvement of patient safety.
Methods: The scoping review was conducted on Ovid MEDLINE, Embase,
and CINAHL. Eligible articles published since 2000 were included.
Results: A total of 4745 articles were identified through the searches,
with 19 included in the final review. The articles included one randomized
control trial. All the included articles had evidence of action after reporting
or investigation of near misses, with the majority showing evaluation of im-
pact. Actions were human, administrative, and engineering focused. Impact
evaluation focused on the reduction of near misses, but without consideration
of patient safety outcome measures, such as harm. The review also noted lim-
ited availability of experimental research and variability in near-miss defini-
tions and that actions are not just the result of near misses.
Conclusions: Currently, health care assumes that reporting and learning
from near misses improves patient safety. The literature provides limited evi-
dence supporting these assumptions and shows that actions as a result of near
misses are commonly aimed at the human. There is a need to prove the benefits
of focusing on near misses in health care and for more system-level actions.
Key Words: near miss, good catch, patient safety, review
(J Patient Saf 2023;19: 42–47)
I t has been many years since health care first recognized the risks
posed to patients by unintended actions and events.1,2 However,
inadvertent harm continues to occur to patients despite safety in-
vestigators across health care trying to learn from events to pre-
vent their recurrence.
Healthcare has traditionally taken a reactive approach to safety,
attempting to learn after harm to patients.3 While learning can and
is taken from harmful events, harm has to have occurred first. This
has led to interest in events that have not caused harm thanks to
the role of defenses or recoveries.4 The identification of and
learning from “near misses” has long been thought valuable
in the improvement of patient safety through the prevention
of harmful events.5,6
It has been more than 20 years since reports first articulated the
need for health care to learn from near misses.1,5,7 Those reports
and many other authors since emphasize how industries, such as
aviation, have learned from near misses and the need for health
care to emulate them.6,8 However, despite those calls, progress
has been slow as demonstrated by a recent scoping review that
From the Faculty of Medicine and Health Sciences, School of Medicine, Uni-
versity of Nottingham, Nottingham, United Kingdom.
Correspondence: Nick Woodier, BMBS, CErgHF, MSc, Rm E/C1719, Queen’s
Medical Centre, School of Medicine, University of Nottingham, Queen’s
Medical Centre, Nottingham, NG7 2UH, United Kingdom (e‐mail:
Nicholas.Woodier1@nottingham.ac.uk).
The authors disclose no conflict of interest.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
42 www.journalpatientsafety.com
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
identified that research to date has focused on contributory factors
to near misses and their reporting.9
One factor inhibiting the reporting of near misses is the percep-
tion that there is little value in reporting them.10,11 Near misses do
not cause harm12 and when balanced with the competing demands
of health care,13 it is understandable why they may not be reported.
The perception of value is further undermined when staff do not see
improvements resulting from their reporting because of limited
feedback.14,15 The research focus on trying to improve near-miss
reporting, as described by Feng et al,9 therefore, seems justified if
they will indeed support improvements in patient safety.
However, the authors of this scoping review, as part of a wider
study of near-miss management in health care, noted difficulties
finding evidence to date that learning from near misses in health
care has improved patient safety. This poses an issue if reporting
is reliant on staff seeing the value of their reports. Does this mean
that the value of learning from near misses is assumed? Is there
evidence that learning from near misses reduces harmful patient
safety events?
If the benefits of learning from near misses in health care are
assumed, that assumption likely originates from the “common
cause hypothesis.”16,17 This hypothesizes that events of differing
severity are linked by their causal factors, meaning that significant
harm events and near misses are the same, but for an intervention.
Heinrich, the original author of the hypothesis, himself stated “pre-
vent the incidents and the injuries will take care of themselves.”18
This has been interpreted as meaning that learning from near misses
will prevent harmful events. The common cause hypothesis has
since been challenged with concerns around how it was devised
and its misapplication.18–20
There is an unanswered question about the value of learning
from near misses in the improvement of patient safety. This question
was not addressed in the scoping review by Feng et al,9 nor has the
question been answered by others. Therefore, the authors set out to
answer the following question through a scoping review: what value
does learning from near misses offer to improve patient safety?
METHODS
A scoping review protocol was developed and registered on the
Open Science Framework.21 The methodology used was that de-
scribed by Khalil et al.22 Findings were reported in line with the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analyses
extension for Scoping Reviews (PRISMA-ScR).23
Inclusion and Exclusion Criteria
Included articles could relate to any health care setting and needed
to consider actions made after single or several patient safety near
misses. Synonymous terms were also searched (good catch and close
call). Patient safety near misses were included, with exclusion of
health and safety near misses. For this review, the authors used the
definition “prevented patient safety incident” for a near miss.7 There
is variability around what is termed a near miss,24 and so this defini-
tion was felt to be appropriately broad to support identification of
J Patient Saf • Volume 19, Number 1, January 2023
J Patient Saf • Volume 19, Number 1, January 2023
suitable articles. This definition also incorporates events termed near
misses according to international frameworks.25,26
Peer-reviewed studies, reviews, and commentaries/editorials that
included evidence in support of the review question were included.
Articles needed to be published in English, after and including the
year 2000. 2000 was chosen because this was the point after which
international reports on patient safety clearly advocated for a focus
on near misses.1,2 Commentaries/editorials without evidence, letters,
comments, and viewpoints were excluded.
Search Strategy and Information Sources
The initial (stage one) search used terms identified from the pa-
tient safety literature and discussions with experts in safety science.
Terms were refined after initial searching of Ovid MEDLINE to
create the final (stage 2) strategy.
After the initial search, maternity, obstetric, and neonatal near
misses were excluded. These near misses are defined differently,
referring to situations, which almost resulted in death27 and are
different to patient safety near misses.28
Final searches were undertaken using Ovid MEDLINE, Embase,
and CINAHL (EBSCO) in September 2021 and refreshed in August
2022. The search used the terms “near miss*,” “close call*,” and
“good catch*.” Further terms were not used to ensure a significant
yield from the databases to avoid missing articles. The MeSH term
“Near Miss, Healthcare” was used for Ovid MEDLINE. Searches
identified 4745 articles after removal of duplicates.
Selection Process and Data Charting
Search results were downloaded into referencing software. The
authors undertook an initial screen of titles and abstracts for arti-
cles that met the inclusion criteria. A second review then identi-
fied any that met exclusion criteria. For those that met inclusion,
but not exclusion criteria, full texts were requested. Reference lists
of full-text articles were reviewed for further articles.
A data extraction form was agreed to standardize the variables
extracted from each article. Data included study characteristics
(e.g., year and country of publication), research study type and de-
sign, and population of focus (primary care setting and incident
[near-miss] type mapped against the World Health Organization’s
framework26). For data around the review question, variables in-
cluded what events were termed near misses, patient outcomes
from the near misses, what actions were developed to prevent fu-
ture events as a result, whether the actions were implemented,
whether impact was evaluated, and the results of evaluation.
The authors acted as 3 independent reviewers. Reviewers met
to resolve any conflicts. No formal critical appraisal was under-
taken; however, limitations and any recognized quality issues were
noted. The objective of a scoping review is comprehensive cover-
age, rather than identifying standards or quality of evidence.29
RESULTS
Nineteen articles were included in the final scoping review
as per Figure 1. The supplementary materials provide a sum-
mary of the 19 articles. Most originated from the United States
(n = 16), having been published since 2010 (n = 18). There
was one randomized control trial30 and one quasi-experimental
study,31 with the rest being quantitative nonexperimental studies
(n = 10), quality improvement projects (n = 6), and mixed
methods (n = 1). The primary care setting in all articles was “gen-
eral hospital” across single or multiple hospitals (n = 7), or in the
specific specialties of surgery (n = 4), oncology (n = 3, radiation
and chemotherapy), pediatrics (n = 2), emergency care (n = 1), ra-
diology (n = 1), and pharmacy (n = 1). The primary incident (near-
miss) types considered by articles were clinical process (n = 7,
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The Value of Learning From Near Misses
such as wrong procedure, care, implant, or body part), medication
(n = 7, such as prescribing or administering the wrong dose or
drug), and documentation (n = 5, such as wrong patient orders
or incomplete information).
Near-Miss Definitions and Patient Outcomes
During the review, variation in terminology and definitions for
“near miss” were identified by the reviewers. Near miss was the most
common term, with some authors using “good catch.”31–33 Although
review of definitions was not an aim of the scoping review, the
variation is noted here for later consideration as a limitation.
Thirteen articles explicitly defined what they interpreted as a
near miss. Those definitions included context-specific examples
such as “…orders that have been placed for one patient, then
erased and added to another patient’s file by the same clinician
within a 10-minute time frame,”34 and broad examples such as
“…an unintended chain of events that did not reach the patient,
but that could have caused harm if conditions permitted.”32
Eight articles defined or described near misses as situations
where events had not reached the patients.30,32,33,35–39 Ten articles
defined or described near misses that included events that had
reached patients31,34,40–45 and could be considered to potentially
cause harm.46,47 Early et al48 described learning from a “near-
miss sentinel event,” but provided no further information about
the event or its impact.
Actions as a Result of Near Misses
All articles described actions to reduce recurrence of future
events following the analysis of and learning from near misses.
The types of actions implemented were described in varying de-
tail. Some authors provided minimal information about the spe-
cifics of the actions.32,33,38 Several articles also involved multiple
actions.31–33,35–37,40,42,43,45,48 Goolsarran et al,36 for example, in-
troduced education, a screening checklist and an electronic forc-
ing function to reduce near misses associated with incorrect doc-
umentation of metal implants prior to MRI scans.
Human-Focused Actions
Ten articles included evidence of human-focused actions in-
volving staff education and awareness building around safety
risks. Actions included debriefings and huddles,32,35,40 and educa-
tional interventions.31–33,35–37,39,45,48 Yoon et al,39 for example,
developed education for any staff involved in a surgery near miss.
Administrative Actions
Thirteen articles included evidence of administrative actions
involving development of and changes to information sources
directing how tasks and processes should be undertaken. These
included policies, procedures, and guidance,32,33,35,38,40,42–47 as
well as decision-making tools, such as checklists and algorithms.36,48
Fargen et al,46 for example, developed a checklist for use before
interventional procedures.
Several articles also described actions to change processes by directing
staff to undertake them in a different way.32,33,35,38,40,42,43,46,47 Neuspiel
et al42 and Weiss et al,40 for example, changed processes with
the intent of reducing distractions and interruptions.
Engineering Actions
Eleven articles included evidence of engineering actions involving
introduction of or changes to equipment, tools, technology, and envi-
ronments. Changes to digital systems included the introduction of
verification forcing functionality,30,34,43 new functionality to
ensure electronic forms are completed,36 and alerts.30 Adelman
www.journalpatientsafety.com 43
Woodier et al
FIGURE 1. The PRISMA flow diagram for the scoping review of the literature what value does learning from near misses offer to improve
patient safety? Adapted from Tricco et al.23
et al,30 for example, introduced an identification verification alert
and forcing function in their medication ordering system.
Equipment changes included redesign of medication packag-
ing with addition of Tallman lettering37 and upgrading of equip-
ment.35,48 Early et al48 upgraded Wi-Fi and procured new insulin
pens, and Smith-Love35 updated scanning equipment to improve
compliance with barcode-scanning technology. One environmen-
tal action was described with redesign of an outpatient environ-
ment to support efficiency.42
In 3 articles, actions involved the introduction of or upgrades to
electronic near-miss reporting systems to support reporting and
improvements in safety culture.31,32,41 Nyflot et al41 developed
a reporting system and risk index, while Tanz31 implemented a
good-catch reporting program to improve safety attitudes.
Impact Evaluation of Actions
Most articles provided comment on the evaluation of the impact
of their actions. One article, despite the implementation of several
actions, described no evaluation.42 Where there was evaluation, ar-
ticles commonly measured the occurrence of safety events as a met-
ric for impact. Reductions were seen in unintended event rates,
commonly the near misses themselves.30,33,35–41,43–47 Loh et al,47
for example, described a reduction in the number of intraocular lens
events (near misses) from 5.89 before to 3.55 per 1000 cases. Some
articles also demonstrated statistically significant reductions in
event rates.37,39,40,45,46 Yoon et al,39 for example, after introduction
of education found significant reductions in the monthly rates of
their near misses, including improperly performed time-out proce-
dures, which were from 18.7% to 5.9% ( P < 0.0001).
In the one randomized control trial, Adelman et al30 used a
3-armed methodology to evaluate 2 actions aimed at preventing
wrong-patient orders. They found that compared with control,
an identification verification alert reduced the odds of a retract-
and-reorder events (odds ratio, 0.84; 95% confidence interval,
0.72–0.98), and identification re-entry functionality had an even greater
effect (odds ratio, 0.60; 95% confidence interval, 0.50–0.71). Each
event was classified as to its potential for harm if an intervention
had not occurred, and they concluded that 2 events per 100,000
orders would have been life threatening.
A small number of articles considered impact on other facets of
safety, such as compliance with safety functionality, such as using
barcodes,35,48 and safety culture.31–33,41 Lozito et al,32 for example,
demonstrated improvements in scores of a safety culture evaluation.
44 www.journalpatientsafety.com
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J Patient Saf • Volume 19, Number 1, January 2023
Tanz,31 because of significant improvements in scores associated
with knowledge, skills, and attitudes to safety, concluded that
implementation of a good-catch program, and associated actions,
created a culture of safety.
Three articles included extrapolation of findings to describe
impact.30,32,48 Lozito et al32 used the common cause hypothesis
to conclude that their actions would have prevented 1.3 wrong
site, patient, or procedure events. Early et al48 extrapolated im-
provements in the use of barcoding for medication administration
to claim a reduced length of inpatient hospital stay.
Comment on the Limitations of the
Included Articles
The authors of this review noted limitations of the included ar-
ticles. In several articles, it was not clear whether near misses spe-
cifically had resulted in the actions or whether other events may
have influenced.32,40,42,46 In some cases, it was also unclear which
actions, of the multiple implemented, led to the impact.31,35,37,40,43
For example, team huddles that were concluded to have led to im-
provements in the safety of chemotherapy were introduced with
several other actions including the development of standards and
reduced interruptions.40
Other limitations included small data sets41,44 and conclusions
seemingly based on perceptions.45 Loh et al47 showed a reduction
in intraocular lens events but noted that this was affected by the
Hawthorne effect and that the already low number of events made
it challenging to draw conclusions. Several articles also concluded
that learning from near misses would prevent harmful events with-
out providing evidence to substantiate these claims.30,32,34,39,48
DISCUSSION
For more than 20 years, there have been calls for health care
to focus on learning from near misses to improve patient safety.
During this time, efforts have focused on trying to improve
near-miss reporting,9 with beliefs that highlighting the value
of reporting will increase reporting.14,15 However, this assumes that
there is value in learning from near misses and that they improve
patient safety.
The World Health Organization defines patient safety as the
“…absence of preventable harm to a patient….”49 The ultimate
goal of patient safety and the outcome of any related actions is
therefore the reduction of harm to patients. This scoping review,
based on the currently available research, identified no evidence
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J Patient Saf • Volume 19, Number 1, January 2023
that learning from near misses has led to reductions in harm from
patient safety events. These findings currently challenge the value
of learning from near misses to improve patient safety and demon-
strate a need to better understand whether learning from near mis-
ses can reduce harm.
Evidenced Improvements in Patient Safety
Where articles in this scoping review concluded that harm had
been reduced, this was not proven, rather assumed or extrapolated.
Weiss et al,40 for example, significantly reduced chemotherapy
errors that reached the patient and from this concluded that they
would also reduce harm. However, none of the prior events
had themselves caused harm, which was also the case in other
articles.30,35–37 Regarding extrapolation, reduced near-miss
events were used to conclude that harm would have also been
reduced,30,32,48 but these may not be valid conclusions as will be
discussed shortly.
The authors of this scoping review acknowledge that measur-
ing patient safety improvements is difficult and proving the ab-
sence of something such as harm is particularly challenging.
The authors are therefore not concluding that there is no value in
learning from near misses to improve patient safety. Rather, the
conclusion is that current research has not yet provided the evi-
dence of value. There is clear face validity in the assumption that
reducing unintended events, errors, and near misses, must reduce
harm. There is also evidence that learning from near misses im-
proves safety culture,31–33,41 and this in turn will potentially, pos-
itively influence patient safety.
Common Cause Hypothesis and Modern Healthcare
Systems
Despite the findings of this scoping review, the healthcare litera-
ture is rife with statements of the benefits of reporting and learning
from near misses to reduce harm. These beliefs have been influ-
enced by statements in early, seminal reports on patient safety,1,2,7
which in turn have drawn conclusions from other industries50 and
generalized the common cause hypothesis.16
The common cause hypothesis is now controversial.18,19 It has
been challenged with regard to its validity, with evidence for and
against the commonly described belief that learning from and ad-
dressing near misses will reduce harmful events.51–55 There is a
need to test the hypothesis for different types of safety events be-
fore conclusions can be drawn.52 This undermines the extrapola-
tions made in the articles included in this scoping review and
means that they may not have drawn valid conclusions.
The common cause hypothesis is one of several traditional views
of safety that may no longer be applicable in modern healthcare sys-
tems. Safety events may not be as predictable as once thought, in-
stead being situations that emerge in complex systems.56 It may
therefore be necessary for health care to consider near misses from
a different viewpoint, potentially through their role in contrib-
uting to system reliability57 or as a lens through which to consider
system resilience.58
Effective Actions to Improve Patient Safety
This scoping review also provided insights into the actions de-
veloped and implemented to date in health care to reduce future
near misses, safety events, and hopefully harm. With the significant
pressures global health care is facing in the wake of the COVID-19
pandemic, now more than ever, it is important that limited resources
are appropriately allocated to support actions that are most likely to
be effective.
Effective actions will be those that do not require a human to
behave or act in a particular way. Systems require designing to ac-
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The Value of Learning From Near Misses
count for human fallibility and to support the human in practice.
According to action hierarchies, more effective actions will be
those that eliminate hazards, substitute hazards for something less
hazardous, or engineer a way to reduce the potential for hazards to
progress to harm.59,60
In the articles included in this scoping review, there were no
substitution or elimination actions. There were several engineered
actions, with a focus on developing digital safety functionality,
such as via verification functions.30,34 However, more commonly
the actions in the articles were human or administration, and sev-
eral of the engineered actions still relied on humans to act in a par-
ticular way, such as responding to alerts36 and correctly complet-
ing software fields.30 These findings again challenge the current
value of learning from near misses to improve patient safety, and
whether appropriate learning is being taken from near misses to
develop effective actions.
The authors of this review are not concluding that human or
administration actions are inappropriate. Rather, they cannot be
assumed to always be effective, particularly when implemented
alone. Other industries have demonstrated the role of “defense
in depth” by developing multiple opportunities to prevent pro-
gression of events.61 As per van der Schaaf’s original model of near
misses, the final opportunity to recover a situation may be a hu-
man if other defenses have not succeeded.4 Ideally, a human
should not be needed because of well-defined defenses, but if
they are needed, it is preferential for them to know what they
should do when confronted with an unfolding incident. How-
ever, ultimately, it would be preferential to prioritize resource
to address system hazards and develop defenses earlier in an
incident sequence.
CONCLUSIONS
This scoping review challenges current beliefs around the value
of learning from near misses to improve patient safety. There is a
lack of evidence to date that learning from near misses has re-
duced harm, with assumptions having been made of the link be-
tween near misses and harmful events. This scoping review also
challenges the effectiveness of actions implemented to date, after
learning from near misses, to reduce the risk of future safety
events. Without understanding the learning value that may lie
within near misses, health care may be misallocating limited re-
sources to the pursuit of flawed actions that are unlikely to be as
effective as hoped.
Further research is required to ascertain whether near misses
can truly lead to improvements in patient safety through reduc-
tions in harm, how impact of implemented actions can be mea-
sured, and where best actions should be focused to develop effec-
tive defenses to developing incidents. This review also raises ques-
tions about whether it is time for health care to think differently
about near misses, with consideration of how they may contribute
to intelligence in the development of system resilience.
LIMITATIONS
The authors wish to note the following limitations of this re-
view. It is known that underreporting of near misses occurs in
health care,9 and this review has been unable to ascertain the de-
gree to which underreporting has influenced the lack of evidenced
impact from near misses. However, this reviews’ 19 articles pro-
vide insights into actions and impact to date after learning from
near misses.
Further limitations included the lack of experimental research
and the differing definitions used for a near miss across the ar-
ticles. A near miss is not a unique and universal entity, rather it
is interpreted in different ways. An absence of standard
www.journalpatientsafety.com 45
Woodier et al
definitions limits the ability to compare outcomes of learning
from near misses.
REFERENCES
1. Department of Health. An Organisation With a Memory: Report of an
Expert Group on Learning From Adverse Events in the NHS Chaired by the
Chief Medical Office. London, United Kingdom: The Stationary Office; 2000.
2. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer
Health System. Washington, DC: National Academic Press; 2000.
3. Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety
Management. Boca Raton, FL: CRC Press; 2014.
4. van der Schaaf TW. Near Miss Reporting in the Chemical Process Industry.
Eindhoven: Technische Universiteit Eindhoven; 1992.
5. Aspden P, Corrigan JM, Wolcott J. Near-miss analysis. In: Aspden P, ed.
Patient Safety: Achieving a New Standard for Care. Washington, DC:
National Academic Press; 2004.
6. Barach P, Small SD. Reporting and preventing medical mishaps: lessons
from non-medical near miss reporting systems. BMJ. 2000;320:759–763.
7. National Patient Safety Agency. Seven steps to patient safety: the full
reference guide. July 1, 2004. Available at: https://webarchive.
nationalarchives.gov.uk/ukgwa/20171030125518/http://www.nrls.npsa.
nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=
59787. Accessed January 11, 2022.
8. Barach P, Small SD. How the NHS can improve safety and learning. By
learning free lessons from near misses. BMJ. 2000;320:1683–1684.
9. Feng TT, Zhang X, Tan LL, et al. Near miss research in the healthcare
system: a scoping review. J Nurs Adm. 2022;52:160–166.
10. Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing
valuable learning opportunities in radiation oncology. Pract Radiat Oncol.
2021;11:e256–e262.
11. Lee J. Understanding nurses’ experiences with near-miss error reporting
omissions in large hospitals. Nurs Open. 2021;8:2696–2704.
12. Noureldin M, Noureldin MA. Reporting frequency of three near-miss error
types among hospital pharmacists and associations with hospital
pharmacists’ perceptions of their work environment. Res Social Adm
Pharm. 2021;17:381–387.
13. Yan M, Wang M, Al-Hakim L. Barriers to reporting near misses and
adverse events among professionals performing laparoscopic surgeries: a
mixed methodology approach. Surg Endosc. 2021;35:7015–7026.
14. Sudan S, Lewalski P, Arnetz J, et al. The association between attendings’
feedback and residents’ reporting of near misses. BMC Res Notes. 2019;
12:355.
15. Toren O, Dokhi M, Dekeyser GF. Hospital nurses’ intention to report near
misses, patient safety culture and professional seniority. Int J Qual Health
Care. 2021;33:mzab031.
16. Heinrich HW, Petersen DC, Roos N, eds. Industrial Accident Prevention: A
Safety Management Approach. New York: McGraw-Hill; 1980.
17. Heinrich HW. Industrial Accident Prevention: A Scientific Approach. New
York: McGraw-Hill; 1931.
18. Manuele. Reviewing Heinrich: dislodging two myths from the practice of
safety. Prof Saf. 2011;56:52.
19. Manuele FA. Heinrich revisited: truisms or myths. In: Manuele FA, ed.
On the Practice of Safety. John Wiley & Sons, Inc: New Jersey; 2003.
20. Alamgir H, Yu S, Gorman E, et al. Near miss and minor occupational
injury: does it share a common causal pathway with major injury? Am J Ind
Med. 2009;52:69–75.
21. Woodier NL. Does learning from near misses improve healthcare safety?
A scoping review: scoping review protocol. Open Science Forum. 2021.
doi:10.17605/OSF.IO/PBA54.
22. Khalil H, Peters M, Godfrey CM, et al. An evidence-based approach to
scoping reviews. Worldviews Evid Based Nurs. 2016;13:118–123.
46 www.journalpatientsafety.com
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 19, Number 1, January 2023
23. Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping
Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med.
2018;169:467–473.
24. Marks CM, Kasda E, Paine L, et al. “That was a close call”: endorsing a
broad definition of near misses in health care. Jt Comm J Qual Patient Saf.
2013;39:475–479.
25. Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety event
taxonomy: a standardized terminology and classification schema for near
misses and adverse events. International J Qual Health Care. 2005;17:
95–105.
26. World Health Organization. The conceptual framework for the
International Classification for Patient Safety (ICPS). January, 2009.
Available at: https://apps.who.int/iris/bitstream/handle/10665/70882/
WHO_IER_PSP_2010.2_eng.pdf#:~:text=The%20International%
20Classification%20for%20Patient%20Safety%20%28ICPS%29%20is,
which%20existing%20regional%20and%20national%20classifications%
20can%20relate. Accessed January 11, 2022.
27. World Health Organization. Evaluating the quality of care for severe
pregnancy complications: The WHO near-miss approach for maternal
health. 2011. Available at: https://apps.who.int/iris/bitstream/handle/10665/
44692/9789241502221_eng.pdf;sequence=1. Accessed April 22, 2022.
28. Madden I, Milligan F. Enhancing patient safety and reporting near misses.
Br J Midwifery. 2004;12:643–647.
29. McColl MA, Shortt S, Godwin M, et al. Models for integrating
rehabilitation and primary care: a scoping study. Arch Phys Med Rehabil.
2009;90:1523–1531.
30. Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and
preventing wrong-patient electronic orders: a randomized controlled trial.
J Am Med Inform Assoc. 2013;20:305–310.
31. Tanz M. Improving safety knowledge, skills, and attitudes with a good
catch program and student-designed simulation. J Nurs Educ. 2018;57:
379–384.
32. Lozito M, Whiteman K, Swanson-Biearman B, et al. Good catch
campaign: improving the perioperative culture of safety. AORN J. 2018;
107:705–714.
33. Wallace SC, Mamrol C, Finley E. Promote a culture of safety with good
catch reports. Pa Patient Saf Advis. 2017;14.
34. Lombardi D, Gaston-Kim J, Perlstein D, et al. Preventing wrong-patient
electronic orders in the emergency department. J Clin Outcomes Manag.
2016;23:550–554.
35. Smith-Love J. Reducing near miss medication events using an
evidence-based approach. J Nurs Care Qual. 2022;37:327–333.
36. Goolsarran N, Martinez J, Garcia C. Using near-miss events to improve
MRI safety in a large academic centre. BMJ Open Qual. 2019;8:e000593.
37. Tseng HY, Wen CF, Lee YL, et al. Dispensing errors from look-alike drug
trade names. Eur J Hosp Pharm. 2018;25:96–99.
38. Vanderford CE, McKinney KM, Emmons JT. Implementation of pharmacy
to dose: reducing near miss medication errors. Am J Med Qual. 2014;
29:360.
39. Yoon RS, Alaia MJ, Hutzler LH, et al. Using “near misses” analysis to
prevent wrong-site surgery. J Healthc Qual. 2015;37:126–132.
40. Weiss BD, Scott M, Demmel K, et al. Significant and sustained reduction in
chemotherapy errors through improvement science. J Oncol Pract. 2017;
13:e329–e336.
41. Nyflot MJ, Zeng J, Kusano AS, et al. Metrics of success: measuring impact
of a departmental near-miss incident learning system. Pract Radiat Oncol.
2015;5:e409–e416.
42. Neuspiel DR, Stubbs EH, Liggin L. Improving reporting of outpatient
pediatric medical errors. Pediatrics. 2011;128:e1608–e1613.
43. Hyman D, Laire M, Redmond D, et al. The use of patient pictures and
verification screens to reduce computerized provider order entry errors.
Pediatrics. 2012;130:e211–e219.
© 2022 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 19, Number 1, January 2023
44. Ford EC, Smith K, Harris K, et al. Prevention of a wrong-location
misadministration through the use of an intradepartmental incident learning
system. Med Phys. 2012;39:6968–6971.
45. Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing
errors in a district general hospital. Qual Saf Health Care. 2008;17:
146–149.
46. Fargen KM, Velat GJ, Lawson MF, et al. Enhanced staff communication
and reduced near-miss errors with a neurointerventional procedural
checklist. J Neurointerv Surg. 2013;5:497–500.
47. Loh HP, Korne DF, Chee SP, et al. Reducing wrong intraocular lens
implants in cataract surgery. Int J Health Care Qual Assur. 2017;30:
492–505.
48. Early C, Riha C, Martin J, et al. Scanning for safety: an integrated approach
to improved bar-code medication administration. Comput Inform Nurs.
2011;29:157–164 quiz 165-6.
49. World Health OrganizationPatient Safety. September 13, 2019. Available
at: https://www.who.int/news-room/fact-sheets/detail/patient-safety.
Accessed April 22, 2022.
50. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857.
51. Thoroman B, Goode N, Salmon P. System thinking applied to near misses:
a review of industry-wide near miss reporting systems. Theor Issues Ergon
Sci. 2018;19:712–737.
52. Wright L, van der Schaaf T. Accident versus near miss causation: a critical
review of the literature, an empirical test in the UK railway domain, and
their implications for other sectors. J Hazard Mater. 2004;111:105–110.
© 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
The Value of Learning From Near Misses
53. Button K, Drexler J. Are measures of air-misses a useful guide to air
transport safety policy? J Air Transp Manag. 2006;12:168–174.
54. Fabiano B, Currò F. From a survey on accidents in the downstream oil
industry to the development of a detailed near-miss reporting system.
Process Saf Environ Prot. 2012;90:357–367.
55. Köhler F. Barriers to near-miss reporting in the maritime domain. Thesis.
Institutionen för datavetenskap Linköpings universitet. 2010.
56. Leveson NG. Applying systems thinking to analyze and learn from events.
Saf Sci. 2011;49:55–64.
57. van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to
improve patient safety: adapting strategies of high reliability organizations
to healthcare. Curr Opin Otolaryngol Head Neck Surg. 2015;23:292–296.
58. Hollnagel E, Woods DD, Leveson N. Resilience Engineering: Concepts
and Precepts. Boca Raton, FL: CRC Press; 2006.
59. Health & Safety Executive. Management of risk when planning work: the
right priorities. 2011. Available at: https://www.hse.gov.uk/construction/lwit/
assets/downloads/hierarchy-risk-controls.pdf. Accessed January 11, 2022.
60. National Patient Safety Foundation. Action hierarchy tool (part of RCA2):
patient safety essentials toolkit. 2015. Available at: https://www.ashp.org/-/
media/assets/policy-guidelines/docs/endorsed-documents/endorsed-
documents-improving-root-cause-analyses-actions-prevent-harm.ashx.
Accessed March 9, 2022.
61. Chartered Institute of Ergonomics & Human Factors. Barrier management.
December, 2016. Available at: https://archived.ciehf.org/learn/barrier-
management/. Accessed April 22, 2022.
www.journalpatientsafety.com 47