Causes of Near Misses:

Perceptions of Perioperative Nurses

BARBARA COHOON, PhD, RN

ABSTRACT
The purpose of this study was to examine the near-miss experiences of RNs
working in perioperative services to understand their perception of the causes of
near misses. The setting was a multi-facility health care system in the mid-
Atlantic region of the United States. The study design was descriptive, using a
survey of perioperative nurses that was developed for the study. Study partici-
pants could complete up to four surveys for near misses that they personally
experienced in the perioperative setting. Participants ranked six causal factors
(ie, team, workload, task, staff, patient characteristics, hospital characteristics)
according to the extent of that factor’s contribution to the near miss. The team
factor was the most frequently identified cause of near misses, with the top
ranked cause as “communication between team.” Two causal factor subcatego-
ries, “inconsistent information” and “incorrect monitoring,” were predominant in
the near misses reported. The findings from the study provide an understanding
of perioperative nurses’ near-miss experiences and detail the frequency of near
misses as well as identify types of near-miss causes. AORN J 93 (May 2011)
551-565. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.02.017

Key words: near miss, communication, patient safety, nurse perceptions.

O
n December 1, 1999, the Institute of
Medicine (IOM) report To Err is Hu-
man1 broke the news that medical er-
rors are a national health care quality problem.
Preventable medical errors and nonpreventable
adverse events are responsible for unnecessary
morbidity, mortality, and costs to the US health
care system.1-5 A series of reports from the
IOM call attention to the need for immediate
and sweeping reform across the health care in-
dustry to improve the detection and prevention
of medical errors.1,6-11 These reports cite harm
and death caused by medical errors, which are
unacceptable outcomes that must take priority
doi: 10.1016/j.aorn.2010.02.017
© AORN, Inc, 2011
in the improvement of the quality of health
care. What is not shown in these reports is the
number of potential errors, known as near
misses.
Social scientists have discovered that before
an accident occurs in a complex organization,
there often are a number of previous events that
signal the existence of a systemic problem, but
these discrete near-miss events may be over-
looked.12-15 Near misses are important as an
early warning system for impending system
failures, and identifying human, technical, and
organizational recovery efforts may prevent
accidents from occurring. Therefore, more
May 2011 Vol 93 No 5 ● AORN Journal 551
May 2011 Vol 93 No 5 COHOON

information is needed about using the knowl- of the nurses’ recognition and perception of the
edge gained from analyzing near misses to pre- causes of near misses.
vent actual medical errors and improve patient This research questions in this study were as
safety and quality by taking action before sys- follows:
tem failure occurs. 1. What are the types and frequency of near
misses reported by perioperative nurses?
BACKGROUND 2. What are the causes of near misses reported
Each hospital department, such as the periopera-
by perioperative nurses using the Pennsylva-
tive department, may be considered an indepen-
nia Patient Safety Reporting System (PA-
dent entity in a system because of specialized
PSRS) Causal Factors?
processes, yet each department in the organization
The definition of near miss used in this study was
and health care system is dependent on the others.
van Vuuren’s: “a deviation which has clearly sig-
This interdependency between clinical units, cou-
nificant potential consequences.”17(p142)
pled with complex surgical care provided in a
perioperative department, makes this a complex
environment and therefore of interest for quality LITERATURE REVIEW
and safety improvement. I performed a literature review of near misses
reported during the past 50 years and found that
Near Misses in the Perioperative Setting
articles and research have tended to focus mostly
One constant figure throughout the entire surgical
on medication errors, followed by other errors,
procedure is the perioperative nurse, who continu-
and finally the larger concept of medical errors
ously strives to keep the patient free from harm.16
and their general relationship to patient safety. In
Little is known, however, about perioperative
1996, the IOM began an initiative to examine
nurses’ near-miss experiences. Therefore, the pur-
how to improve the quality of care in the United
pose of this study was to gather information about
States.6 Although quality and safety are fre-
perioperative nurses’ perceptions of and experi-
quently written about and studied, I found that
ences with near misses and to gain understanding
near misses rarely receive
attention in the literature.
Plain Language Summary Near misses themselves fi-
nally gained notoriety in the
I used a survey to study how perioperative nurses recognize a near IOM’s 2004 report Patient
miss or close call situation that could result in a health care error Safety: Achieving a New
and their opinions about the causes of near misses. “Inconsistent Standard for Care.11
information,” “incorrect monitoring,” or both were the most fre- In my opinion, the medi-
quently identified types of near misses that could have resulted in cal error incident reporting
a sponge or instrument being left in the incision, surgery being methods used in the US
performed on the wrong side, or surgery being performed on the health care system were
wrong patient. Team factors such as communication between team modeled after Flanagan’s
members were the most frequently reported causes of near misses. critical incident technique.18
This information can be used to develop or revise health care in- The primary purpose of an
stitution policies and procedures. Further research is needed to error-reporting system is to
study this problem in additional perioperative settings and in other provide health care person-
health care settings. nel with a method of verify-
ing that an event occurred,

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CAUSES OF NEAR MISSES
to be able to evaluate it and develop strategies of
identification and prevention to reduce the risk of
subsequent similar incidents.19 This same report-
ing model is used in health care systems for near
misses.
Frequency of Near Misses
The near-miss phenomenon has been studied in
non– health care institutions, such as transporta-
tion, for decades. Several studies have shown that
inclusion and analysis of near-miss event data
elucidate the existence of common causal path-
ways between near-miss events and actual acci-
dents.12,20-22 These findings stimulated non–
health care institution managers to direct their
attention to large numbers of near misses, rather
than to focus exclusively on a smaller number of
serious accidents.22-26 Historically, non– health
care institution managers were the first to identify
and study causes of near misses.
The frequency of near-miss occurrences has
been the subject of debate among patient safety
experts. Health care system managers usually
keep data on incidents internally. In 2002, the
Commonwealth of Pennsylvania passed Act 13,
the Medical Care Availability and Reduction of
Error (MCARE) Act, becoming the first state to
require mandatory reporting of medical errors and
near misses.27,28 The MCARE Act established an
independent state agency called the Patient Safety
Authority, which was tasked with developing an
incident reporting system. These data were pub-
licly released because of a state law.
In April 2005, the Patient Safety Authority re-
leased the 2004 Annual Report,29 its first report to
include in-depth data that had been collected and
analyzed during the year. A total of 427 health
care facilities had submitted 70,851 reports; 95%
of the incidents were categorized as “no harm,”
and the remaining 5% were labeled “serious
events.” According to the PA-PSRS, a no harm
incident is a near miss. The 2005 Annual Report
also demonstrated that near misses occur more
frequently than medical errors.30
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I found limited research performed on near-miss
occurrences in perioperative settings. Studies that I
found focused on anesthesia, transfusion medicine,
and arterial switch surgeries.31-34 The Patient Safety
Authority reports provide a wealth of information
regarding frequency and types of near misses occur-
ring in perioperative settings.29,30
The studies that I reviewed predominantly used
qualitative research methods.35-42 Two studies
used quantitative methods, involving regression
analysis.33,34 One used a mixed-methods approach
involving both a survey and an open-ended re-
sponse reporting form.43 These initial studies pro-
vide a foundation for understanding the phenome-
non of near misses, but additional studies need to
be performed to determine the role of near misses
in ensuring patient safety.
METHODS
I chose a descriptive research design using a
mixed-methods approach to analyze near misses
experienced by perioperative nurses. The frame-
work used for this study was van Vuuren’s 1998
modified version44 of the Simple Model of Inci-
dent Causation created by Van der Schaaf in
1992.45 I used data from the perioperative nurses’
survey that I developed and administered for this
study to examine the near-miss experiences of
RNs working in perioperative settings at a multi-
facility health system in the mid-Atlantic region
of the United States.
POPULATION AND SAMPLE
The population comprised approximately 377
nurses working in perioperative settings where
general surgery was performed in five hospitals of
the participating health care system. I conducted a
power analysis for this study that indicated that a
sample size of 100 surveys and a volunteer (ie,
convenience) sample of no fewer than 25 periop-
erative nurses (ie, approximately four surveys
from each participant) were required. I presented
the study protocol at each hospital’s perioperative
staff meetings, in preoperative, intraoperative, and
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postoperative settings. Perioperative nurses in at- veys after three months and continued with the
tendance who wished to participate provided me study because I had more than the statistically
with their contact information. I left participation required 100.
information with the director of each periopera-
tive setting for distribution to perioperative nurses HUMAN PARTICIPANT PROTECTION
who were unable to attend the staff meeting. I obtained permission for the study through a uni-
Thus, all 377 potential participants had the oppor- versity human subjects review board and the par-
tunity to contact me and volunteer to participate. ticipating health care system’s institutional review
Other health care board. I designed the
professionals who near miss survey to
were not RNs and be voluntary and
In the causal factor section of the survey,
RNs who did not participants ranked categories beneath the anonymous. I made
work in the partici- causal factor categories: team categories, sure that there was
pating health care workload factors, task factors, staff factors, no identifiable infor-
system’s periopera- patient characteristics, and hospital mation linking the
tive settings were characteristics. participant to a re-
excluded. turned survey. Only I
I recruited poten- saw and handled
tial participants from the total of 91 perioperative completed informed
nurses who provided their contact information by consents and near miss surveys, which were
sending them a packet by US mail that contained mailed independently. I kept the information in a
secure location, and all data in this study were
 my contact information;
confidential. Data were reported in aggregate and
 two copies of the informed consent;
not individually.
 instructions about study participation, includ-
ing how respondents should complete the sur-
SURVEY OF PERIOPERATIVE NURSES
veys; and
I conducted the data collection for this study by
 stamped, addressed envelopes to enable them
means of a 24-item near miss survey of perioper-
to directly return all materials to me.
ative nurses. The survey contained three sections:
Those who agreed to participate signed one copy  general information (items 1-7, 9, 17-24);
of the informed consent and returned it to me  recovery factors (item 8); and
separately by mail. The participants retained the  causal factors (items 10-16).
other copy of the informed consent. I continued
The near miss survey was divided into six causal
accepting participants until I reached the desired
factor categories, based on the PA-PSRS:
sample size of no fewer than 25 perioperative
nurses—approximately five from each participat-  team factors,

ing hospital. The final sample included all nurses  workload factors,

who returned informed consents, a total of 55 of  task factors,

377 for a response rate of 15%.  staff factors,

I mailed four near miss surveys to each partici-  patient characteristics, and

pant with instructions to provide written responses  hospital characteristics.

for up to four near misses that they experienced Participants ranked each of the categories listed
personally in the perioperative setting. I collected beneath the causal factors on a scale of zero to
a total of 163 surveys. I stopped collecting sur- 10, where zero was “not a contributor” and 10

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CAUSES OF NEAR MISSES
was “complete contribution/definite cause of
near miss.” In addition to the listed categories,
respondents also had the option to rank “other”
categories that contributed to near-miss events.
I developed the survey from the PA-PSRS with
permission. The PA-PSRS survey uses an Auto-
mated Data Interface XML46 that was developed at
the ECRI Institute with assistance from Electronic
Data Systems, a global technology service. The sur-
vey was used as part of the Commonwealth of
Pennsylvania Patient Safety Authority’s 2004 direc-
tive.28 The PA-PSRS Automated Data Interface
XML was pilot tested for organizational reporting of
errors and near misses between November 2003 and
March 2004 in 440 hospitals, ambulatory surgical
facilities, and birthing centers in Pennsylvania.
According to John R. Clarke, MD, clinical direc-
tor at the Pennsylvania Patient Safety Authority, the
PA-PSRS “is improved based on annual feedback
from reporters to queries of face validity, construct
validity, content validity, and representation validity.
[The instrument] has not been successfully tested for
convergent validity, criterion validity, or concurrent
validity” (e-mail communication, November 2010). I
calculated a reliability estimate for the quantitative
portion of the near miss survey, resulting in a Cron-
bach’s alpha of .746. I established content validity
for the survey using the expert opinions of five RN
experts (ie, a statistical researcher and risk manag-
ers) who were involved in health care system qual-
ity control and had experience using patient safety
instruments for reporting of medical errors and near
misses. Their review resulted in 100% agreement.
DATA ANALYSIS
I used quantitative and qualitative approaches to
analyze near-miss incidents experienced by peri-
operative nurses. I retrieved the data; cleaned it
(ie, prepared it for analysis by performing checks
to ensure that the data were consistent and cor-
rect); entered it into a computer spreadsheet; and
exported it to SPSS 15.047 for statistical analysis.
I coding the data from the open-ended survey
questions by hand and analyzed the data for recur-
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ring themes using Ricoeur’s analytical steps.48 I
performed qualitative analysis on the open-ended
responses, such as the comments added to the
“other” category. This allowed me to determine pat-
terns in the responses and additional contributing
factors after a nurse’s observation of a near-miss
event. I established inter-rater reliability of categori-
cal coding of themes by having an expert in qualita-
tive research methods and patient safety indepen-
dently review a copy of the themes to determine
whether the expert identified the same themes.49
FINDINGS
Forty-seven of 55 perioperative nurses completed
near miss surveys. This comprised 12% of the total
number of perioperative nurses in the system; 52%
of participants who initially showed interest com-
pleted surveys. Of the 220 near miss surveys sent
out, 74% (N ⫽ 163) were returned.
Characteristics of Study Respondents
The sample of participating perioperative nurses
consisted of 45 women (96%) and two men (4%).
The number of years of practice reported by the
RNs at the time of the near miss ranged from six
months to 40 years, with a mean of 17 years. The
years of experience as a perioperative nurse at
the participating health care facility at the time of
the near miss ranged from one month to 28.5
years, with a mean of 7.4 years.
Descriptive Analysis
The date with the highest number of reported
near misses (3%) for the total number of near
misses reported was October 25, 2007. Near-
miss events were reported on every day of the
week, but Tuesday had the highest number of
near misses (24%) during the week. The time
of day the near misses took place ranged from
12:30 AM to 6 PM.
The survey provided choices of location: the OR
(46%); the postanesthesia care unit, which was listed
as “recovery room” on the survey (16%); and pre-
operative holding (35%). The remaining 3% of near
misses occurred in other areas.
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Findings Reported by Research Question

TABLE 1. Perioperative Nurses Near Miss
There were six causal factor categories used in
Survey Results by Types of Near Misses
the near miss survey. In the six causal factors, I
found two subcategories, “inconsistent informa- Number returned
tion” (47.2%) and “incorrect monitoring” (37.4%) Causal factors (percentage
or both (15.3%), to be predominant in the periop- subcategories of total)
erative setting for the total number of near misses Incorrect monitoring 61 (37.4%)
reported. On further examination of the total  Potential contamination  16 (9.8%)
 Tests  14 (8.6%)
number of near misses reported for types of
 Equipment  9 (5.5%)
near misses in these subcategories, 16 types of  Supply needed  8 (4.9%)

near misses in the perioperative setting emerged  Transfer  8 (4.9%)

 Complications from  4 (2.5%)
in two subcategories, “incorrect monitoring”
surgery
and “inconsistent information.” I performed  No check-in procedure  2 (1.2%)
qualitative analyses to identify common themes done
and causal factor categories that were not in- Inconsistent information 77 (47.2%)
cluded in the PA-PSRS near miss reporting in-  Medication  26 (15.9%)
 Order entry  8 (4.9%)
strument. The results of the data analysis re-
 Wrong dosage  4 (2.5%)
ported in this section are organized according  Wrong medication  2 (1.2%)

to the two research questions.  Patient allergic to  2 (1.2%)

the medication
Research question 1: types and frequency  Wrong medication  5 (3.1%)
 Wrong mixture  4 (2.5%)
of near misses. Sixteen types of near misses
 Wrong dose  3 (1.8%)
were reported in the perioperative setting (Table  Omitted  3 (1.8%)

1). “Potential contamination” (n ⫽ 16, 9.8%)  Adverse reaction  2 (1.2%)

and “tests” (n ⫽ 14, 8.6%) were the two most  Wrong site  1 (0.6%)

 Allergy  17 (10.4%)
frequent types of near misses reported under  Cross-allergic reaction  10 (6.1%)
the “incorrect monitoring” subcategory. “Incon-  Latex  4 (2.5%)

sistent information” (n ⫽ 77, 47.2%) was the  Documentation  3 (1.8%)

 Informed consent  13 (8.0%)

other most frequently cited causal factor subcat-
 Label  12 (7.4%)
egory in the perioperative setting, and “medica-  Documentation in the  5 (3.1%)
tion” (n ⫽ 26, 15.9%) and “allergy” (n ⫽ 17, patient’s chart
 Identification bracelet 4 (2.5%)
10.4%) were the most frequently reported types 

of near misses in this subcategory. Of the med- Near misses fitting into both 25 (15.3%)
subcategories
ication-related near misses, the most frequently
 Wrong count  13 (8.0%)
reported type was “order entry” (n ⫽ 8, 4.9%).  Wrong side surgery  7 (4.3%)
Of the allergy-related near misses, the most re-  Wrong patient  5 (3.1%)
ported type was “cross-allergic reaction” (n ⫽ Total number of surveys returned ⫽ 163. Types of near misses ⫽ 16.
10, 6.1%).
“Wrong count,” “wrong side surgery,” and
“wrong patient” were types of reported near example, one respondent wrote about a wrong
misses found to fit either or both the “incorrect count: “A counted [sponge] was placed under
monitoring” and “inconsistent information” sub- the sterile tourniquet cuff by doctor but infor-
categories, depending on the circumstance. For mation not relayed to surgical staff.”

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Of the 25 near misses reported that fell under enced staff member(s)” and “inadequate super-
both the “incorrect monitoring” and “inconsistent vision” (Table 4).
information” subcategories, the most frequently  Staff factor (n ⫽ 103, 63%)—Among these,
cited was “wrong count” (n ⫽ 13, 8%). This was “proficiency issue” was found to be the big-
followed by “wrong side surgery” (n ⫽ 7, 4.3%) gest contributor to near misses, followed by
and “wrong patient” (n ⫽ 5, 3.1%). “fatigue” and “insufficient staff” (Table 5).
 Patient characteristics (n ⫽ 34, 21%)—The
Research question 2: causes of near
misses. The reporting scale had a range of zero patient characteristic found to contribute most
to 10, with zero indicating not a contributor, 1 indi- to near misses was “lack of patient under-
cating minimal contribution, and 10 indicating com- standing” (Table 6).
plete involvement. Respondents could choose more
than one causal factor. Higher scores on the causal
TABLE 3. Workload Causal Factors Rating
factors scale of the near miss survey indicated com-
plete contribution or definite cause of the near miss.
Actual
Among near misses reported, “team factor” Scale or subscale range* Mean (SD)
was the most frequently identified cause and “pa-
Workload factor
tient characteristics” was the least frequently iden- Distractions 0-10 3.45 (3.74)
tified. For the 163 surveys received, findings re- Interruptions 0-10 2.91 (3.54)
lated to PA-PSRS causal factors were as follows: Limited access to 0-10 1.30 (2.72)
patient information
 Team factor (n ⫽ 141, 87%)—Among team Other 0-10 1.13 (2.98)
factor causes reported, “communication be- High noise level 0-10 1.04 (2.48)
tween team” was attributed as having the Poor lighting 0-10 0.60 (1.97)
highest contribution to near misses (Table 2). Equipment malfunction 0-10 0.36 (1.62)
Unavailable equipment 0-10 0.36 (1.58)
 Workload factor (n ⫽ 119, 73%)—Perioperative
N ⫽ 119; respondents could select more than one response.
nurses assigned “distractions” as the factor * Possible range, 0-10.
contributing most to a near miss and “inter-
ruptions” second (Table 3).
 Task factor (n ⫽ 114, 70%)—“Training issue”
was ranked the highest, followed by “inexperi- TABLE 4. Task Causal Factors Rating

Actual
TABLE 2. Team Causal Factors Rating Scale or subscale range* Mean (SD)
Task factors
Actual
Training issue 0-10 2.69 (3.74)
Scale or subscale range* Mean (SD)
Inexperienced staff 0-10 2.23 (3.40)
Team factor member(s)
Communication between team 0-10 5.99 (4.10) Inadequate 0-10 1.24 (2.77)
Cross-coverage 0-10 1.64 (3.2) supervision
Change of service 0-10 1.56 (3.12) Other 0-10 1.01 (2.75)
Other 0-10 1.23 (3.11) Emergency situation 0-10 0.96 (2.60)
Shift change 0-10 1.20 (2.87) Order entry problem 0-10 0.66 (2.18)
Unplanned workload 0-10 0.87 (2.16) Cardiac or 0-10 0.08 (0.79)
Holiday 0-10 0.17 (0.98) respiratory arrest

N ⫽ 141; respondents could select more than one response. N ⫽ 114; respondents could select more than one response.
* Possible range, 0-10. * Possible range, 0-10.

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TABLE 5. Staff Causal Factors Rating TABLE 7. Hospital Characteristics Causal

Factors Rating
Actual Mean
Scale or subscale range* (SD) Actual Mean
Scale or subscale range* (SD)
Staff factors
Proficiency issue 0-10 2.07 (3.50) Hospital characteristics
Fatigue 0-10 1.12 (2.40) Policy(s) not followed 0-10 3.34 (4.25)
Insufficient staff 0-10 1.12 (2.52) Procedure(s) not followed 0-10 2.95 (4.15)
Inadequate system for covering 0-10 0.92 (2.39) Lack of procedure 0-10 1.09 (2.64)
patient care Lack of policy 0-10 1.01 (2.63)
Other 0-10 0.86 (2.64) Unclear or ambiguous policy 0-10 0.96 (2.44)
Scheduling of staff 0-9 0.56 (1.80) Unclear or ambiguous 0-10 0.82 (2.30)
Float staff 0-10 0.44 (1.74) procedure
Use of agency [staff] 0-10 0.24 (1.26) Other 0-10 0.45 (2.01)
Traveling staff 0-9 0.18 (0.99) Presence of observation 0-7 0.18 (1.06)
Impairment issue 0-8 0.17 (0.95) patient
Use of temporary [staff] 0-9 0.15 (1.01) Unavailable pharmacy 0-10 0.13 (1.11)
Inadequate bed availability 0-10 0.07 (0.79)
N ⫽ 103; respondents could select more than one response.
* Possible range, 0-10. Presence of boarder patient/ 0-10 0.07 (0.79)
different services

N ⫽ 108; respondents could select more than one response.

* Possible range, 0-10.
TABLE 6. Patient Characteristics Causal
Factors Rating

Actual Mean “distractions” (3.45, SD 3.74) and “policy(s) not

Scale or subscale range* (SD) followed” (3.34, SD 4.25) (Table 8).
Patient characteristics
Lack of patient understanding 0-10 0.86 (2.53)
“Other” Causal Factor Subcategories
Lack of compliance or 0-10 0.44 (1.93) Participants chose the near-miss events to re-
adherence by patient port for inclusion in the study. The participants’
Other 0-10 0.44 (1.88) descriptions of the near-miss events had to be
Language barrier 0-10 0.27 (1.53)
Lack of family cooperation 0-10 0.16 (1.02)
consistent with the definition of near miss used
in this study. Eighty-three (51%) of the total
N ⫽ 34; respondents could select more than one response.
* Possible range, 0-10. number of near misses reported included com-
ments about “other contributing factors.” I per-
formed qualitative analysis on perioperative
 Hospital characteristics (n ⫽ 108, 66%)— nurses’ comments describing the near misses
The respondents identified “policy(s) not and the other causal factor subcategories and
followed” as the number one hospital char- found several causes that did not fit in the
acteristic contributor, followed by “proce- causal factor subcategories in the provided sur-
dure(s) not followed” and “lack of proce- vey. I identified the following themes: “present-
dure” (Table 7). ing conditions,” “outside department was in-
volved,” “command climate,” “inadequate
Causal factor ranking order. The top-ranked hospital physical workspace,” “inconsistent in-
cause of near misses reported by perioperative formation,” “thought I needed to do it myself,”
nurses was “communication between team” (5.99, “thought someone else had done it already or
standard deviation [SD] 4.10). This was followed by checked it,” “became complacent to details or

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TABLE 8. Top 10 Causal Factor Rating
Causal subcategory
Communication between team
Distractions
Policy(s) not followed
Procedure(s) not followed
Interruptions
Training issue
Inexperienced staff member(s)
Proficiency issue
Cross-coverage
Change of service
Respondents could select more than one response.
* Possible range, 0-10.
not paying attention,” and “incorrect monitor-
ing.” Examples of the reported near misses
demonstrate these additional identified themes.
Presenting conditions. I identified three types
of “presenting condition” causes of near misses:
abnormal laboratory work, size of patient, and pre-
senting infection(s). One respondent’s comment typ-
ified presenting conditions as a cause:
I went to interview my patient before surgery
in the holding area for hip surgery. The opera-
tive site was okay but the patient had a [ban-
dage] on his right toe on the same side as the
surgery. I removed the [bandage] to inspect
the site and it was an old non-healing ulcer on
his little toe. The doctor checked it and can-
celled the surgery for further work up on his
toe.
Outside department. Under the subcategory of
“outside department was involved,” respondents’
comments centered on the emergency department,
other nursing units, the laboratory, the blood bank, a
surgeon’s office, and presurgical admittance. One
response illustrates the concerns about involvement
of other departments:
Patient was sent down from room to be pre-
oped for surgery. He was over the age of 50.
He had been seen first in [the emergency de-
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partment] where the EKG [electrocardiogram]
was done. Then sent upstairs where he was
seen by the in-house doctor. Coming down to
Mean (SD)*
us the EKG on his chart was of a different pa-
5.99 (4.10)
tient. Patient insisted he never had one done at
3.45 (3.74)
3.34 (4.25) all.
2.95 (4.15)
Command climate. I identified two theme sub-
2.91 (3.54)
2.69 (3.74) groups under “command climate”: “employee diffi-
2.23 (3.40) cult to work with” and “being hurried or pushed to
2.07 (3.50) proceed.” One respondent commented,
1.64 (3.20)
1.56 (3.12) We were finishing up our OR schedule the day
before Thanksgiving. I was finishing up, clean-
ing the room when the anesthesiologist rolled
into the OR with the last case of the day. I did
not see the patient to interview him nor did I
check to see if all required consents, forms,
labs, etc. were on the chart. When I confronted
the Dr. he initially ignored me. When I asked
him again why he came back to the room he
stated, “I want to get this last case done with.”
We hadn’t even started opening for that case.
Another respondent stated, “Patient was almost
brought back to the OR without seeing the doctor
before surgery.”
Inadequate hospital physical workspace. An
example of the theme subcategory “inadequate
hospital physical workspace” identified by peri-
operative nurses was illustrated by the follow-
ing statement:
Doctor ordered PCA [patient-controlled anal-
gesia] pump for pain control. Orders on coun-
ter. PCA pump is then left on counter . . . Tem-
porary nurse (RN) starts to hook up pump . . .
Thus pump is set up not near patient’s bed but
at counter.
Inconsistent information. An example of the
theme subcategory “inconsistent information”
identified in reported near misses was as fol-
lows: “I noticed that the signed surgical consent
for surgery identified the patient’s right hip as
the surgical site. The surgical board as well as
AORN Journal 559
May 2011 Vol 93 No 5
the schedule identified the left hip as the cor-
rect surgical site.”
Thought I needed to do it myself. An exam-
ple demonstrating the theme subcategory “thought
I needed to do it myself” included the following
comments:
An inpatient came for the creation of an AV
[arteriovenous] fistula in his upper arm. The
OR schedule and posting slip said the site was
the left upper arm. The patient’s informed con-
sent was signed for the right upper arm. The
anesthesiologist stated either could be used for
phlebotomy as long as it was distal to the sur-
gery site. I was going to draw blood from the
right forearm and the charge nurse told me if I
drew from the surgical arm the surgery would
be cancelled. I did not draw the blood and
waited for the surgeon to confirm the surgical
site.
The danger in this example that could have moved
the event to a medical error is the fact that the
nurse began to perform the procedure by herself.
It took someone else’s intervention to stop her,
which allowed the event to become a near miss.
Thought someone else had done it already
or checked it. Near misses reported by periop-
erative nurses identified the theme subcategory
“thought someone else had done it already or
checked it.” One respondent made the following
comment:
We were going to operate on the right-hand
thumb, when during the surgical pause,
[I noticed] the consent form said “left side
thumb.” I immediately informed the surgeon
. . . It was fortunate that the correct site was
prepped before we began surgery.
Became complacent to details or not pay-
ing attention. Under the subcategory theme
“became complacent to details or not paying at-
tention,” one respondent commented, “I put the
wrong consent on the chart. The consent was for
another patient with the same type of surgery.”
560 AORN Journal
COHOON
Another respondent noted, “I was in a hurry and
as I was labeling my specimens, I put the previ-
ous patient’s labels on the specimen containers.”
Incorrect monitoring. The “incorrect monitor-
ing” subcategory was exemplified by one respon-
dent who stated, “I did not initially notice that the
patient would not be donating his own blood, and
so I didn’t order the ABO [and] RH antibody
tests required.”
DISCUSSION
This section discusses the study findings of the
type, frequency, and causes of near misses experi-
enced by perioperative nurses. The discussion is
organized according to the research questions, and
it includes quantitative and qualitative findings.
Research Question 1: Types and
Frequency of Near Misses
Perioperative nurses identified a variety of differ-
ent types of near misses. Many were pertinent to
the unique perioperative setting, including no
check-in procedure done, informed consent errors,
complications from surgery, potential contamina-
tion, wrong count, and wrong site surgery. The rest
were of a broader nature. These included medica-
tion, allergy, documentation in patient’s chart, iden-
tification bracelet, transfer, supply needed, equip-
ment, tests, wrong patient, and labels.
Through qualitative analysis, I identified two
themes that describe types of near misses: “in-
consistent information” and “incorrect monitor-
ing.” “Inconsistent information” occurred fre-
quently in the perioperative setting and often
involved outside departments. Patients were
seen preoperatively in their surgeon’s office,
where information was collected. Informed con-
sents were often rewritten before surgery be-
cause they had been improperly filled out and
signed by the patient at the surgeon’s office.
Incorrect labels were discovered after they had
been applied to a specimen, which could have
led to a patient receiving the wrong diagnosis.
CAUSES OF NEAR MISSES www.aornjournal.org

“Incorrect monitoring” revolved around the It is not uncommon for medications to be the
failure to recognize or respond accurately to the subject of the highest reported near-miss experi-
situation, such as when perioperative nurses ence. The Patient Safety Authority’s 200530 and
forgot to check expiration dates on supplies 200652 reports indicated that medication-related
when they initially pulled them for the upcom- near misses were the highest reported category in
ing surgical procedure. Another example was the PA-PSRS. Further analysis of the findings
when the perioperative nurse lost track of a from this study on medication-related near misses
counted item, such as a sponge placed around illustrates seven different subcategories. In de-
the tourniquet. scending order of frequency, they were “order
“Inconsistent infor- entry,” “wrong medi-
mation” leading to cation,” “wrong mix-
near misses empha- Under the “incorrect monitoring” subcategory, ture,” “wrong dose,”
sizes the importance potential contamination was the highest near “omitted,” “adverse
of the Joint Commis- miss unique to the perioperative setting, and reaction,” and “wrong
sion’s first National medication and allergy-related near misses site.”
Patient Safety Goal of were reported most frequently under Allergy-related
improving the accu- “inconsistent information.” near misses were the
racy of patient identi- second highest sub-
50
fication. The find- category under “in-
ings of this study also were consistent with a recent consistent information” and included three sub-
Patient Safety Authority report.51 According to the types: “cross-allergic reaction,” “latex,” and
Patient Safety Authority’s research on wrong site “documentation.” Perioperative nurses discovered
surgery, errors were associated with misinformation cross-allergic reaction most frequently. Cross-
and misperceptions in communication. Misinforma- allergic reaction happens because a variety of
tion was found on labels, OR schedules, and in- prep solutions are contained in OR surgical packs.
formed consents. The Patient Safety Authority re- Some patients were allergic to povidone-iodine,
port stated that two-thirds of near misses in the OR for example, and this important piece of informa-
involved misinformation.51 During the Patient tion was often not relayed to the perioperative
Safety Authority’s research, investigators found a team.
correlation between the number of facility re-
ports of incorrectly scheduled surgical proce- Research Question 2: Causes of
dures and wrong site surgeries: for every 10 Near Misses
reports, one wrong site surgery error occurred According to respondents, the top 10 causes of near
in the perioperative setting. misses were “communication between team,” “dis-
Under the “incorrect monitoring” subcategory, tractions,” “policy(s) not followed,” “procedure(s)
potential contamination was the highest near miss not followed,” “interruptions,” “training issue,” “in-
unique to the perioperative setting, and medica- experienced staff member(s),” “proficiency issue,”
tion and allergy-related near misses were reported “cross-coverage,” and “change of service.” Higher
most frequently under “inconsistent information.” scores on the causal factors contribution scale of the
Based on what the perioperative nurses identified survey indicated a definite cause of the near miss.
and given what is known from other studies re- Of 163 surveys, respondents reported the causal
ported in the literature, these findings are consis- factor category of “team factor” most frequently as
tent with the types of near misses reported in the contributing factor. The next were “workload
other health care settings.30,52 factor,” “task factor,” “hospital characteristics,” and

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May 2011 Vol 93 No 5
“staff factor.” “Patient characteristics” was the least
frequently identified contributing factor. Based on
the respondents’ reports, “team factor” also was re-
lated to the perioperative nurses’ work environment
and organizational structure.
Working in a perioperative setting involves a
team; a number of health care professionals and
non– health care employees play integral roles.
The 2006 Patient Safety Authority report also
showed team factors to be the most frequent con-
tributing factor for near misses and medical
errors.52
In this study, perioperative nurses reported “com-
munication between team” as the highest contributor
to near misses. This was followed by “cross-
coverage,” “change of service,” “shift change,” “un-
planned workload,” and “holiday.” Communication
is frequently ranked as the number one contributing
factor in other studies. According to the Patient
Safety Authority’s 2006 report, communication was
the most frequently cited contributing factor.52 The
Joint Commission also identifies communication
issues as a major root cause of sentinel events.50
Communication occurs on three fronts in the
perioperative setting: communication between
outside departments and the perioperative depart-
ment, such as laboratory and surgeons’ offices;
communication between staff members in the pre-
operative, intraoperative, and postoperative areas
as patients travel in the perioperative continuum;
and communication between team members, at
least four people interacting during any given sur-
gical procedure, usually involving the anesthesia
care provider, surgeon, scrub person, and circulat-
ing nurse. Given the number of personnel in the
perioperative setting and health care setting, it is
understandable that “communication between
team” was chosen as the number one causal
factor.
Under “workload factor,” perioperative nurses
assigned “distraction” as the highest contributor
to a near miss. “Interruptions” was second, fol-
lowed by “limited access to patient information,”
“high noise level,” “poor lighting,” “equipment
562 AORN Journal
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malfunction,” and “unavailable equipment.” “Dis-
traction” was found to be the highest contributor
to near misses in “workload factor,” but more
importantly, “distractions” ranked second overall
and “interruptions” was fifth. These findings are
consistent with those identified in other studies
that documented the high occurrence of distrac-
tions and interruptions in the perioperative set-
ting.53,54 In one study, distractions and interrupti-
ons occurred during every surgical procedure at a
rate of 0.29 events per minute.53 These distrac-
tions and interruptions directly affected the ability
of perioperative team members to work effec-
tively.54 AORN also has been concerned about
distractions and interruptions, recommending fur-
ther research on the types of distractions and in-
teractions that occur in the perioperative setting.55
Under “task factors,” “training issues” was
ranked as the most important contributor to near
misses, followed by “inexperienced staff mem-
ber(s),” “inadequate supervision,” “emergency situa-
tion,” “order entry problem,” and “cardiac/respira-
tory arrest.” Under “staff factors,” “proficiency
issues” was identified as the most important contrib-
utor, followed by “fatigue,” “insufficient staff,”
“inadequate system for covering patient care,”
“scheduling of staff,” “float staff,” “use of agency
[staff],” “traveling staff,” “impairment issue,” and
“use of temporary [staff].”
“Patient characteristics” findings included “lack
of patient understanding,” the leading contributor,
followed by “lack of compliance or adherence by
patient,” “language barrier,” and “lack of family
cooperation.” Under “hospital characteristics,”
“policy(s) not followed” was the most important
contributor, followed by “procedure(s) not fol-
lowed,” “lack of procedure,” “lack of policy,”
“unclear or ambiguous policy,” “unclear or am-
biguous procedure,” “presence of observation pa-
tient” (ie, a surgical patient who is kept in the
postanesthesia care unit longer than usual because
a bed is not available), “unavailable pharmacy”
(ie, the inability of the perioperative nurse to ac-
cess or obtain medication because the hospital
CAUSES OF NEAR MISSES
pharmacy was not available), “inadequate bed
availability,” and “presence of boarder patient/
different services” (ie, a surgical patient is held in
the perioperative area because there are no hospi-
tal beds available).
These findings are consistent with earlier stud-
ies and reports. The Commonwealth of Pennsyl-
vania’s PA-PSRS,29,30 the Joint Commission,50
and research performed by Seiden and Barach56
have shown the following to be causal factors:
assessing staffing effectiveness and dealing with
agency and float staff, inservice programs or con-
tinuing education and training, team training,
compliance with policies and procedures, design
and use of equipment, fatigue, wrong procedure,
and behavior or attitude issues.
Fifty-one percent of 163 respondents in this
study included written responses identifying
“other contributing factors” (ie, factors that did
not fit with the Commonwealth of Pennsylvania’s
PA-PSRS Causal Factor subcategories). Through
qualitative analysis of these open-ended re-
sponses, I derived themed causal factor subcate-
gories: “outside department,” “command climate,”
“inadequate hospital physical workspace,” and
“inconsistent information.” My decision to add
“outside departments” reflects the day-to-day in-
teraction between the perioperative setting and
interdependent departments and nursing units,
such as the emergency department, laboratory,
surgeon’s office, and presurgical admittance. Sup-
port for “outside departments” as a contributor to
near-miss events in the perioperative setting also
was observed in van Vuuren’s research.44
I found two theme subgroups under “com-
mand climate”: “employee difficult to work
with” and “being hurried or pushed to pro-
ceed.” This finding is consistent with the Pa-
tient Safety Authority’s research on wrong site
surgery.51 It links disruptive behavior by sur-
geons to an increase in wrong site surgeries.
“Being hurried or pushed to proceed” also was
identified by the Patient Safety Authority’s risk
www.aornjournal.org
factors for wrong site surgery as time pressures
and organizational cultural factors.51
The remaining theme subcategories that I iden-
tified were “thought I needed to do it myself,”
“thought someone else had done it already or
checked it,” “became complacent to details or not
paying attention,” and “incorrect monitoring.” The
Joint Commission’s recognition of these same
subcategories substantiates the need for additional
subcategories in the Commonwealth of Pennsyl-
vania’s PA-PSRS. Findings similar to these were
observed in another study related to perioperative
nurses’ confusion over responsibility and nurse
reliance on others to inspect surgical case carts.57
Until these additional subcategories of data col-
lection are added into the PA-PSRS and the Joint
Commission systems, the ability to correctly iden-
tify the contributing factors of near-miss events
will continue to be inadequate.
LIMITATIONS
Limitations of this study are related to low re-
sponse rate, size of the sample, and participants
enrolled using a convenience sample, which limit
generalizability of these findings. These findings
may only be applicable to the setting in which the
study occurred: five hospitals in one health care
system.
FURTHER RESEARCH
The findings of this study add to what is known
about perioperative nurses’ near-miss experiences
and provide an understanding of the frequency and
types of near misses and their causes from the per-
spective of the perioperative nurse. Future research
should be conducted to include RNs from periopera-
tive settings in other health care systems, along with
other nursing units, to gather additional information
about RNs’ experiences—not just perioperative
nurses’ experiences—with near misses. Health care
systems could use this information to make internal
policy and procedure changes. Also, replication of
this study in other geographical regions will provide
valuable information for state and federal policy
AORN Journal 563
May 2011 Vol 93 No 5
makers in determining whether to make reporting of
near misses mandatory versus voluntary.
The design of this study allowed for descrip-
tive analysis. Findings were of individual periop-
erative nurses’ perceptions of near misses. Future
research needs to examine system failures and
institutional-level phenomena.
References
1. Institute of Medicine. In: Kohn LT, Corrigan JM,
Donaldson MS, eds. To Err is Human: Building a
Safer Health System. Washington, DC: The National
Academies Press; 2000.
2. Bates DW, Spell N, Cullen DJ, et al. The costs of ad-
verse drug events in hospitalized patients. Adverse
Drug Events Prevention Study Group. JAMA. 1997;
277(4):307-311.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of
adverse events and negligence in hospitalized patients:
results of the Harvard Medical Practice Study I. N Engl
J Med. 1991;324(6):370-376.
4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidents
and types of adverse events and negligent care in Utah
and Colorado. Med Care. 2000;38(3):261-271.
5. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of
medical injuries in Utah and Colorado. Inquiry. 1999;
36(3):255-264.
6. Crossing the Quality Chasm: the IOM Health Care
Quality Initiative. Institute of Medicine. http://
www.iom.edu/Global/News%20Announcements/
Crossing-the-Quality-Chasm-The-IOM-Health-Care-
Quality-Initiative.aspx. Accessed August 23, 2010.
7. Institute of Medicine, Committee on Quality of Health
Care in America. Crossing the Quality Chasm: A New
Health System for the 21st Century. Washington, DC:
The National Academies Press; 2001.
8. Corrigan JM, Greiner A, Erickson SM, eds. Fostering
Rapid Advances in Health Care: Learning from System
Demonstrations. Washington, DC: The National Acade-
mies Press; 2003.
9. Greiner AC, Knebel E, eds. Health Professions Educa-
tion: A Bridge to Quality. Washington, DC: The Na-
tional Academies Press; 2003.
10. Adams K, Corrigan JM, eds. Priority Areas for Na-
tional Action: Transforming Health Care Quality.
Washington, DC: The National Academies Press; 2003.
11. Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds.
Patient Safety: Achieving a New Standard for Care.
Washington, DC: The National Academies Press; 2004.
12. Principles of accident prevention. In: Heinrich HW,
Petersen D, Roos N. Industrial Accident Prevention: A
Safety Management Approach. 5th ed. New York, NY:
McGraw-Hill; 1980:20-94.
13. Leape LL, Woods DD, Hatlie MJ, Kizer LW, Schroeder
SA, Lundberg GD. Promoting patient safety by preventing
medical error. JAMA. 1998;280(16):1444-1447.
14. Studies of human error. In: Reason J. Human Error.
New York, NY: Cambridge University Press; 1990:
19-52.
564 AORN Journal
COHOON
15. Preface. In: Spath PL, ed. Error Reduction in Health
Care: A Systems Approach to Improving Patient Safety.
San Francisco, CA: Jossey-Bass; 2000:xxv-xxix.
16. Watson DS. Introduction to SafetyNet: lessons learned
from close calls in the OR. AORN J.2006;84(Suppl 1):
S7-S9.
17. van der Schaaf TW, Lucas DA, Hale AR. Conclusions.
In: van der Schaaf TW, Lucas DA, Hale AR, eds.
Near Miss Reporting as a Safety Tool. Oxford, Eng-
land: Butterworth-Heinemann; 1991:137-148.
18. Flanagan JC. The critical incident technique. Psychol
Bull. 1954;51(4):327-358.
19. Defensive documentation. In: Sharpe CC. Nursing Mal-
practice: Liability and Risk Management. Westport,
CT: Auburn House; 1999:89-104.
20. Brown GR. Use of traffic conflicts for near miss report-
ing. In: van der Schaaf TW, Lucas DA, Hale AR, eds.
Near Miss Reporting as a Safety Tool. Oxford, Eng-
land: Butterworth-Heinemann Ltd; 1991:111-125.
21. Fahlbruch B, Wilpert B, Vincent C. Approaches to
safety. In: Vincent C, de Mol B, eds. Safety in Medi-
cine. Oxford, England: Elsevier Science Ltd; 2000:9-29.
22. Wright L, van der Schaaf T. Accident versus near miss
causation: a critical review of the literature, an empiri-
cal test in the UK railway domain, and their implica-
tions for other sectors. J Hazard Mater. 2004;111(1-3):
105-110.
23. Report of CCPS/OECD Conference and Workshop on
Chemical Accident Investigations. Paris, France: Or-
ganisation for Economic Co-operation and Develop-
ment. OECD Environment, Health and Safety Publica-
tions; 2002. http://www.oecd.org/dataoecd/59/35/
1947162.pdf. Accessed June 28, 2010.
24. Davies JB, Wright L, Courtney E, Reid H. Confidential
incident reporting on the UK railways: the “CIRAS”
system. Cogn Technol Work. 2000;2(3):117-125.
25. Jones S, Kirchsteiger C, Bjerke W. The importance of
near miss reporting to further improve safety perfor-
mance. J Loss Prev Process Industries. 1999;12(1):
59-67.
26. Phimister JR, Oktem U, Kleindorfer PR, Kunreuther H.
Near-miss incident management in the chemical process
industry. Risk Anal. 2003;23(3):445-459.
27. Medical Care Availability and Reduction of Error
(MCARE) Act. Act of Mar. 20, 2002, P.L. No. 13 40;
2002. Available at: http://www.portal.state.pa.us/portal/
server.pt/document/495911/hb1082_pdf. Accessed
August 23, 2010.
28. Patient Safety Authority. 2003 Annual Report. 2004.
http://patientsafetyauthority.org/PatientSafetyAuthority/
Documents/cover_letter_and_annual_report.pdf. Ac-
cessed August 23, 2010.
29. Patient Safety Authority. 2004 Annual Report. 2005.
http://patientsafetyauthority.org/PatientSafetyAuthority/
Documents/psa_annual_report_for_2004_-_final_elec_
version.pdf. Accessed June 29, 2010.
30. Patient Safety Authority. 2005 Annual Report. 2006.
http://patientsafetyauthority.org/PatientSafetyAuthority/
Documents/annual_report_for_2005_final_version.pdf.
Accessed June 29, 2010.
31. Runciman WB, Sellen A, Webb RK, et al. The Austra-
lian Incident Monitoring Study. Errors, incidents and
CAUSES OF NEAR MISSES
accidents in anaesthetic practice. Anaesth Intensive
Care. 1993;21(5):506-519.
32. Kaplan HS, Battles JB, van der Schaaf TW, Shea CE,
Mercer SQ. Identification and classification of the
causes of events in transfusion medicine. Transfusion.
1998;38(11-12):1071-1081.
33. de Leval MR, Carthey J, Wright DJ, Farewell VT,
Reason JT. Human factors and cardiac surgery: a multi-
center study. J Thorac Cardiovasc Surg. 2000;119(4 Pt
1):661-672.
34. de Leval MR, François K, Bull C, Brawn W,
Spiegelhalter D. Analysis of a cluster of surgical
failures. Application to a series of neonatal arterial
switch operations. J Thorac Cardiovasc Surg. 1994;
107(3):914-924.
35. Balas M, Scott LD, Rogers AE. The prevalence and
nature of errors and near errors reported by hospital
staff nurses. Appl Nurs Res. 2004;17(4):224-230.
36. Barach P, Small SD. Reporting and preventing medical
mishaps: lessons from non-medical near miss reporting
systems. BMJ. 2000;320(7237):759-763.
37. Battles JB, Shea CE. A system of analyzing medical
errors to improve GME curricula and programs. Acad
Med. 2001;76(2):125-133.
38. Cohoon BD. Learning from near misses through reflec-
tion: a new risk management strategy. J Healthc Risk
Manag. 2003;23(2):19-25.
39. Henneman EA, Gawlinski A. A “near-miss” model for
describing the nurse’s role in the recovery of medical
errors. J Prof Nurs. 2004;20(3):196-201.
40. Jeffe DB, Dunagan WC, Garbutt J, et al. Using focus
groups to understand physicians’ and nurses’ perspec-
tives on error reporting in hospitals. Jt Comm J Qual
Saf. 2004;30(9):471-479.
41. Meurier CE. Understanding the nature of errors in nurs-
ing: using a model to analyse critical incident reports of
errors which had resulted in an adverse or potentially
adverse event [Nursing and Health Care Management
Issues]. J Adv Nurs. 2000;32(1):202-207.
42. Rosenthal MM, Cornett PL, Sutcliffe KM, Lewton E.
Beyond the medical record: other modes of error ac-
knowledgement. J Gen Intern Med. 2005;20(5):404-
409.
43. Schmidt CE, Bottoni T. Improving medication safety
and patient care in the emergency department. J Emerg
Nurs. 2003;29(1):12-16.
44. van Vuuren W. Organizational Failure: An Exploratory
Study in the Steel Industry and the Medical Domain
[doctoral dissertation]. The Netherlands: Eindhoven
University of Technology; 1998.
45. van der Schaaf TW. Near Miss Reporting in the Chemi-
cal Process Industry [doctoral dissertation]. The Neth-
erlands: Eindhoven University of Technology; 1992.
www.aornjournal.org
46. Part 2 of 3—XML document definition. Version 6.4.
In: PA-PSRS Automated Data Interface XML Specifica-
tion. Plymouth Meeting, PA: Commonwealth of Penn-
sylvania Patient Safety Authority; September 18, 2007.
http://patientsafetyauthority.org/PA-PSRS/Documents/
part2-xmldocumentdefinition.pdf. Accessed June 29,
2010.
47. SPSS—Statistical Package for the Social Sciences [soft-
ware]. Version 15.0. Chicago, IL: SPSS, Inc; 2006.
48. Phenomenology as method. In: Streubert HJ, Carpenter
DR. Qualitative Research in Nursing: Advancing the
Humanistic Imperative. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 1999:43-63.
49. Guba EG, Lincoln YS. Effective Evaluation. San Fran-
cisco, CA: Jossey-Bass, Inc; 1981.
50. National Patient Safety Goals: Hospital. The Joint
Commission. http://www.jointcommission.org/assets/1/
6/2011_NPSGs_HAP.pdf. Accessed January 22, 2011.
51. Patient Safety Authority releases wrong-site surgery
data [news release]. Harrisburg, PA: Pennsylvania
Patient Safety Authority; June 26, 2007. http://patient
safetyauthority.org/NewsAndInformation/PressReleases/
2007/Pages/pr_2007_June_26.aspx. Accessed June 29,
2010.
52. Patient Safety Authority. 2006 Annual Report. 2007.
http://patientsafetyauthority.org/PatientSafetyAuthority/
Documents/annual_report_2006.pdf. Accessed June 29,
2010.
53. Healey AN, Sevdalis N, Vincent CA. Measuring intra-
operative interference from distraction and interruption
observed in the operating theater. Ergonomics. 2006;
49(5-6):589-604.
54. Healey AN, Primus CP, Koutantji M. Quantifying dis-
traction and interruption in urological surgery. Qual Saf
Health Care. 2007;16(2):135-139.
55. Beyea S. Monitoring and measuring errors and adverse
events across the surgical continuum. AORN J. 2002;
75(3):613-614.
56. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-
procedure, and wrong-patient adverse events: are they
preventable? Arch Surg. 2006;141(9):931-939.
57. Fowler PH, Craig J, Fredendall LD, Damali U. Periop-
erative workflow: barriers to efficiency, risks, and satis-
faction. AORN J. 2008;87(1):187-208.
Barbara Cohoon, PhD, RN, is the deputy di-
rector of government relations at National Mili-
tary Family Association, Alexandria, VA. Dr
Cohoon has no declared affiliation that could
be perceived as posing a potential conflict of
interest in the publication of this article.
AORN Journal 565