Woodier, Nicholas
(2023)
Improving patient safety by learning from near misses – insights from safety-critical industries.
PhD thesis, University of Nottingham.
Abstract
Background
Patients are at risk of being harmed by the very processes meant to help them. To improve patient safety, healthcare organisations attempt to identify the factors that contribute to incidents and take action to optimise conditions to minimise repeats. However, improvements in patient safety have not matched those observed in other safety-critical industries.
One difference between healthcare and other safety-critical industries may be how they learn from near misses when seeking to make safety improvements. Near misses are incidents that almost happened, but for an interruption in the sequence of events. Management of near misses includes their identification, reporting and investigation, and the learning that results. Safety theory suggests that acting on near misses will lead to actions to help prevent incidents. However, evidence also suggests that healthcare has yet to embrace the learning potential that patient safety near misses offer.
The aims of this research, in support of this thesis, were to explore how best healthcare can learn from patient safety near misses to improve patient safety, and to identify what guidance non-healthcare safety-critical industries, which have implemented effective near-miss management systems, can offer healthcare. As this research progressed the aims were updated to include consideration of whether healthcare should seek to learn from patient safety near misses.
Methods
This research took a mixed-methods approach augmented by scoping reviews of the healthcare (study 1) and non-healthcare safety-critical industry (study 3) literature. A qualitative case study (study 2) was undertaken to explore the management of patient safety near misses in the English National Health Service. Seventeen interviews were undertaken with patient safety leads across acute hospitals, ambulance trusts, mental health trusts, primary care, and national bodies. A questionnaire was also used to help access the views of frontline staff.
A grounded theory (study 4) was used to develop a set of principles, based on learning from non-healthcare safety-critical industries, around how best near misses can be managed. Thirty-five interviews were undertaken across aviation, maritime, and rail, with nuclear later added as per the theoretical sampling.
Results
The scoping reviews contributed 125 healthcare and 108 non-healthcare safety-critical industry academic articles, published internationally between 2000 and 2022, to the evidence gained from the qualitative case study and grounded theory. Safety cultures and maturity with safety management processes were found to vary in and across the different industries, and there was a reluctance for healthcare to learn about safety and near misses from other industries.
Healthcare has yet to establish effective processes to manage patient safety near misses. There is an absence of evidence that learning has led to improvements in patient safety. The definition of a patient safety near miss varies, and organisations focus their efforts on reporting and investigating incidents, with limited attention to patient safety near misses. In non-healthcare safety-critical industries, near-miss management is more established, but process maturity varies in and across industries. Near misses are often defined specifically for an industry, but there is limited evidence that learning from them has improved safety. Information about near misses are commonly aggregated and may contribute to company and industry safety management systems.
Exploration of the definition of a patient safety near miss led to the identification of the features of a near miss. The features have not been previously defined in the manner presented in this thesis. A patient safety near miss is context-specific and complex, involves interruptions, highlights system vulnerabilities, and is delineated from an incident by whether events reach a patient.
Across healthcare and non-healthcare safety-critical industries the impact of learning from near misses is often assumed or extrapolated based on the common cause hypothesis. The hypothesis is regularly cited in safety literature and is used as the basis for justifying a focus on patient safety near misses. However, the validity of the hypothesis has been questioned and has not been validated for different patient safety near miss and incident types.
Conclusions
The research findings challenge long-held beliefs that learning from patient safety near misses will lead to improvements in patient safety. These beliefs are based on traditional safety theory that is unlikely to now be valid in the complexity of modern-day systems where incidents are the result of multiple factors and can emerge without apparent warning. Further research is required to understand the relationship between learning from patient safety near misses and patient safety, and whether the common cause hypothesis is valid for different types of healthcare safety event.
While there are questions about the value of learning directly from patient safety near misses, the contribution of near misses to safety management systems in non-healthcare safety-critical industries looks to be beneficial for safety improvement. Safety management systems have yet to be implemented in the National Health Service and future research should look to understand how best this may be achieved and their value. In the meantime, patient safety near misses may help healthcare’s understanding of systems and their optimisation to create barriers to incidents and build resilience. This research offers an evidence-based definition of a patient safety near miss and describes principles to support identification, reporting, prioritisation, investigation, aggregation, learning, and action to help improve patient safety.
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