Near miss (safety)

A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near. Although the label of 'human error' is commonly applied to an initiating event, a faulty process or system invariably permits or compounds the harm, and should be the focus of improvement. Other familiar terms for these events is a "close call", or in the case of moving objects, "near collision" or a near hit.

Reporting, analysis and prevention

Most safety activities are reactive and not proactive. Many organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss producing events but are largely ignored because nothing (no injury, damage or loss) happened. Employees are not enlightened to report these close calls as there has been no disruption or loss in the form of injuries or property damage. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations. History has shown repeatedly that most loss producing events (accidents) were preceded by warnings or near accidents, sometimes also called close calls, narrow escapes or near hits.^[1]

• In terms of human lives and property damage, near misses are cheaper, zero-cost learning opportunities (compared to learning from actual injury or property loss events)
• Getting a very high number of near misses is the goal; it is possible to achieve a ratio of 100 near misses reported per loss event^[2]
• Achieving and investigating a high ratio of near misses will find the causal factors and root causes of potential future accidents, resulting in about 95% reduction in actual losses^[3]
• An ideal near miss event reporting system includes both mandatory (for incidents with high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and the factors that prevented loss from occurring.
• The events that caused the near miss are subjected to root cause analysis to identify the defect in the system that resulted in the error and factors that may either amplify or ameliorate the result.
• To prevent the near miss from happening again, the organization must institute teamwork training, feedback on performance and a commitment to continued data collection and analysis, a process called continuous improvement.
• Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus, capturing near misses not only provides an inexpensive means of learning, but also has some equally beneficial spin offs:^{[citation needed]}
  • Captures sufficient data for statistical analysis; trending studies.
  • Provides immense opportunity for "employee participation," a basic requirement for a successful workplace health and safety program. This embodies principles of behavior shift, responsibility sharing, awareness, and incentives.
  • One of the primary workplace problems near miss incident reporting attempts to solve directly or indirectly is to try to create an open culture whereby everyone shares and contributes in a responsible manner. Near-Miss reporting has been shown to increase employee relationships and encourage teamwork in creating a safer work environment.^[4]

Safety improvements by reports

Reporting of near misses by observers is an established error reduction technique in many industries and organizations:

Aviation

• In the United States, the Aviation Safety Reporting System (ASRS) has been collecting confidential voluntary reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after TWA Flight 514 crashed on approach to Dulles International Airport near Washington, D.C., killing all 85 passengers and seven crew in 1974. The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles air traffic controllers, and that earlier another airline had told its pilots, but not other airlines, about a similar near miss. The ASRS identifies deficiencies and provides data for planning improvements to stakeholders without regulatory action. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this program. Due to near miss observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, to one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997.^[5]
• In the United Kingdom, an aviation near miss report is known as an "airprox", by the Civil Aviation Authority. Since reporting began, aircraft near misses continue to decline.^[6]

Fire-rescue services

• The rate of fire fighter fatalities and injuries in the United States is unchanged for the last 15 years despite improvements in personal protective equipment, apparatus and a decrease in structure fires.^[7] In 2005, the National Fire Fighter Near-Miss Reporting System was established, funded by grants from the U.S. Fire Administration and Fireman’s Fund Insurance Company, and endorsed by the International Associations of Fire Chiefs and Fire Fighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses, or is told of a near-miss event. The report may be anonymous, and is not forwarded to any regulatory agency.^[8]

Healthcare

• AORN, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near miss reporting system (SafetyNet ^[9]), covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members.
• The Patient Safety Reporting System (PSRS) is a program modeled upon the Aviation Safety Reporting System and developed by the United States Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports.^[10]
• The Near Miss Registry is a risk free, anonymous reporting tool for near misses in Internal Medicine. It is sponsored by the New York State Department of Health and administered by the New York Chapter of the American College of Physicians. This tool collects information about both near miss medical errors and the barriers that kept these errors from reaching patients.
• AlmostME^[11] is another commercially offered solution for near-miss reporting in healthcare.

Rail

• CIRAS (the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the University of Strathclyde for use in the Scottish rail industry. However, after the Ladbroke Grove rail crash, John Prescott mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous Charitable trust.^[12]

See also

• Air safety
• Error
• Hazard analysis
• Maternal near miss
• Patient safety
• Road-traffic safety
• Root cause
• Root cause analysis
• Safety engineering
• Separation (air traffic control)

References

External links

• Columbia Journalism Review:‘Near Miss’