Professional Documents
Culture Documents
119 Rectation
119 Rectation
NEAR MISS
RECORDS MANAGEMENT The Occupational Safety and Health Administration (OSHA) near-
miss is a potential hazard or incident in which no property was
IMORTANT? - Record Keeping is a vital part of nursing practice. It is essential for the damaged, and no personal injury was sustained, but where, given
accurate and effective care of patients. It includes the legal documentation which is a slight shift in time or position, damage or injury easily could have
needed for patient care.
occurred.
Nursing documentation is written evidence verifying that the nurse or healthcare They are a precursor to accidents and are opportunities to identify
professional ‘s authorized or moral responsibilities were met in order for nursing care to hazards and unsafe conditions. It goes without saying that
be assessed. Well-written, timely, and accurate documentation is an integral part of reporting near misses is a critical tool to create solutions, prevent
nursing practice, whether a nursing student, new nurse, or experienced nurse. It not only accidents and injuries in the future and improve your safety culture
helps make the job easier for you, but helps open up the line of communication between overall.
the healthcare team and the patients.. Healthcare facilities and professionals should
Near misses are also referred to as “close calls”, “narrow escapes”
continue working together in order to continually improve their clinical documentation
policies and systems. or “miss accidents”
You are not required to report near misses to OSHA. But they do
1. SENTINEL EVENTS recommend recording near miss cases.
A Sentinel Event is defined by The Joint Commission (TJC) as any There are two main types of near miss incidents — unsafe condition
unanticipated event in a healthcare setting resulting in death or near miss and unsafe act near miss.
serious physical or psychological injury to a patient or patients, not Unsafe condition - Circumstances, environment, or state of
related to the natural course of the patient's illness. equipment which could lead to an accident occurring.
Sentinel events specifically include loss of a limb or gross motor Unsafe act - Behavior that can potentially lead to damage of
function, and any event for which a recurrence would carry a risk of property, personal injury, or death. It’s often related to ignoring
a serious adverse outcome. Sentinel events are identified under TJC procedures and is signaling the need for new rules.
accreditation policies to help aid in root cause analysis and to assist
EX. common near miss scenarios include:
in development of preventative measures.
The Joint Commission tracks events in a database to ensure events Non-injury caused due to falling from heights including stairs, Mobile
are adequately analysed and undesirable trends or decreases in elevated work platforms (MEWA), rooftops and more
performance are caught early and mitigated.
Slippery conditions that could have led to slips or trips that cause serious
Sentinel events include "unexpected occurrences involving death or serious injuries or dislocations.
physical or psychological injury, or the risk thereof" and all of the following, Working on machinery without proper Lockout or Tagout procedures
even if the outcome was not death or major permanent loss of function: (LOTO).
Working without proper personal protective equipment PPE like helmets,
– Infant abduction, or discharge to the wrong family. gloves, etc.
– Unexpected death of a full-term infant. Severe neonatal jaundice Risky or negligent behavior in several scenarios like driving heavy
(bilirubin over 30 milligrams/deciliter). machinery above the prescribed speed limit.
– Surgery on the wrong individual or wrong body part.
Close shave caused due to improper training or maintenance of
– Instrument or object left in a patient after surgery or another procedure.
machinery.
– Rape in a continuous care setting.
– Suicide in a continuous care setting, or within 72 hours of discharge.
Evading the path of a falling object
– Hemolytic transfusion reaction due to blood Near miss caused due to improper or no signage which could lead
– group incompatibilities. employees to enter otherwise restricted zones without isolations
– Radiation therapy to the wrong body region or 25% above the planned A worker slips while carrying a heavy load but manages to catch
dose themselves before falling.
A machine malfunctions and causes a loud noise but does not cause any
EVENT TYPES-National Accreditation Board for Hospitals & Healthcare Providers (NABH) damage.
1. Surgical events - (wrong body part/ patient/procedure, retained A chemical spill is quickly cleaned up before anyone is exposed to it.
instrument, death during the procedure, anesthesia related events) A worker trips on a loose power cord but does not fall.
Smoke is seen coming from an electrical outlet, but there is no fire.
2. Device or Product events - (contaminated drugs and device, unintended A car almost hits a pedestrian in a crosswalk.
use, breakdown or failure) An elevator door starts to close but opens again when someone steps in
front of it.
3. Patient protection events - (infant discharge, elopement, suicide, A piece of machinery breaks but does not cause any injuries.
attempted suicide, self-harm, intentional injury, nosocomial infection,
A gas leak is detected and fixed before it causes any harm.
medical gas)
A worker slips on a wet floor but does not fall.
4. Environmental events - (burn, slip, trip, fall, electric shock, use of A computer crashes, but no data is lost.
restrains and bed rails)