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Stucky CH, Michael Hartmann J, Yauger YJ, Romito KJ, Bradley DF, Baza G, Lorenz ME, House SL, Dindinger RA, Wymer JA, Miller MJ, Knight AR. Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies. J Perianesth Nurs 2024; 39:10-15. [PMID: 37855761 DOI: 10.1016/j.jopan.2023.06.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 10/20/2023]
Abstract
Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.
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Affiliation(s)
- Christopher H Stucky
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl Kirchberg, Rheinland-Pfalz, Germany.
| | - J Michael Hartmann
- Adult Gerontology-Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Young J Yauger
- TriService Nursing Research Program (TSNRP), Bethesda, MD
| | - Kenneth J Romito
- Adult Gerontology-Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - David F Bradley
- Adult Gerontology-Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Gaston Baza
- Adult Gerontology-Clinical Nurse Specialist Program, Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Megan E Lorenz
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl Kirchberg, Rheinland-Pfalz, Germany
| | - Sherita L House
- School of Nursing, University of North Carolina at Greensboro, Greensboro, NC
| | - Rebeccah A Dindinger
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl Kirchberg, Rheinland-Pfalz, Germany
| | - Joshua A Wymer
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA
| | - Melissa J Miller
- Center for Nursing Science and Clinical Inquiry, Womack Army Medical Center, Fort Liberty, NC
| | - Albert R Knight
- Center for Nursing Science and Clinical Inquiry, Landstuhl Regional Medical Center, Landstuhl Kirchberg, Rheinland-Pfalz, Germany
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