Nursing Outlook
Volume 54, Issue 2 , Pages 85-93 , March 2006

Reporting near-miss events in nursing homes

References 

  1. Mitchell PH . Nursing is essential to improving patient safety . J Adv Nurs . 2002;38:109–110
  2. Hughes RG . First, do no harm (avoiding the near misses) . Am J Nurs . 2004;104:81–84
  3. Kohn LT , Corrigan JM , Donaldson MS . To err is human: building a safer health system. Executive summary . Washington, DC: National Academy Press; 2000;
  4. Buerhaus PI . Lucian Leape on patient safety in U.S. hospitals . Image J Nurs Sch . 2004;36:366–370
  5. Gabrel C , Jones A . The national nursing home survey (1995 summary national center for health statistics) . Vital Health Statistics . 2000;13(146):
  6. Gurwitz JH , Sanchez-Cross MT , Eckler M , Matulis J . The epidemiology of adverse and unexpected events in the long-term care setting . J Am Geriatr Soc . 1994;42:33–38
  7. Braun J , Capezuti E . A medico-legal evaluation of dehydration and malnutrition among nursing home residents . Elder LJ . 2000;8:239–290
  8. Gurwitz JH , Field TS , Avorn J , McCormick D , Jain S , Eckler M , et al.   Incidence and preventability of adverse drug events in nursing homes . Am J Med . 2000;109:87–94
  9. Coleman EA , Martau JM , Lin MK , Kramer AM . Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA ’87 . J Am Geriatr Soc . 2002;50:728–732
  10. Rubenstein LZ , Josephson KR , Robbins AS . Falls in the nursing home . Ann Intern Med . 1994;121:442–451
  11. Wagner LM , Capezuti E , Taylor JA , Sattin RW , Ouslander JG . Impact of a falls menu-driven incident reporting system on documentation and quality improvement in nursing homes . The Gerontologist . 2005;45:835–842
  12. Kapp MB . Resident safety and medical errors in nursing homes (reporting and disclosure in a culture of mutual distrust) . J Leg Med . 2003;24:51–76
  13. Barach P . The end of the beginning (lessons learned from the patient safety movement) . J Leg Med . 2003;24:7–27
  14. Sokol P , Cummins DS . A needs assessment for patient safety education (focusing on the nursing perspective) . Nurs Econ . 2002;20:245–248
  15. Braun J . Risk management (incident reports) . Long-Term Care Litig . 2001;1:9
  16. Lawton R , Parker D . Barriers to incident reporting in a healthcare system . Qual Saf Health Care . 2002;11:15–18
  17. Battles JB , Kaplan HS , Van der Schaaf TW , Shea CE . The attributes of medical event-reporting systems (experience with a prototype medical event reporting system for transfusion medicine) . Arch Pathol Lab Med . 1998;122:231–238
  18. Barach P , Small SD . Reporting and preventing medical mishaps (lessons from non-medical near miss reporting systems) . Br Med J . 2000;320:759–763
  19. Barach P , Small SD . How the NHS can improve safety and learning . Br Med J . 2000;320:1683–1684
  20. Firth-Cozens J . Barriers to incident reporting . Qual Saf Health Care . 2002;11:7
  21. Reinertsen JL . Let’s talk about error (leaders should take responsibility for mistakes) . Br Med J . 2000;320:730
  22. Pattinson RC , Hall M . Near misses (a useful adjunct to maternal death enquiries) . Br Med Bull . 2003;67:231–243
  23. Affonso D , Jeffs L . Near misses (lessons learned in the processes of care) . International Nursing Perspectives . 2004;4:115–122
  24. Aspden P , Corrigan JM , Wolcott J , Erickson SM . Patient safety (achieving a new standard for care) . Washington, DC: The National Academies Press; 2004;
  25. Department of Veterans Affairs . Veterans Health Administration (VHA) National Patient Safety Improvement Handbook . Washington, DC: US Department of Veterans Affairs; 2002;
  26. Bates DW , Cullen DJ , Laird NM , Peterson LA , Small SD , Servi D , et al.   Incidence of adverse drug events and potential adverse drug events . JAMA . 1995;274:29–34
  27. Balas M , Scott LD , Rogers AE . The prevalence and nature of errors and near errors reported by hospital staff nurses . Appl Nurs Res . 2004;17:224–230
  28. Clarke SP , Rockett JL , Sloane DM , Aiken LH . Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses . Am J Infect Control . 2002;30:207–216
  29. Rudman WJ , Brown CA , Hewitt CR , Carpenter WO , Campbell B , Tubb T , et al.   The use of data mining tools in identifying medication error near misses and adverse drug events . Top Health Inf Manage . 2002;23:94–103
  30. Kaplan HS . Benefiting from the “Gift of Failure” (essentials for an event reporting system) . J Leg Med . 2003;24:29–35
  31. McCafferty MH , Polk HC . Addition of “near-miss” cases enhances a quality improvement conference . Arch Surg . 2004;139:216–217
  32. Billings C . Appendix B: incident reporting systems in medicine and experience with the aviation system reporting system. Report from a workshop on assembling the scientific basis for progress on patient safety . 1998; Available at: http://www.npsf.org/exec/billings.html;1 Accessed October 1, 2005
  33. Gaba D . Anaesthesiology as a model for patient safety in health care . Br Med J . 2000;320:785–788
  34. Cooper JB , Newbower RS , Long CD , McPeak B . Preventable anaesthesia mishaps (a study of human factors) . Anesthesiology . 1978;49:399–406
  35. Saxena S , Ramer L , Shulman IA . A comprehensive assessment program to improve blood-administering practices using the FOCUS-PDCA model . Transfusion . 2004;44:1350–1356
  36. Callum JL , Kaplan HS , Merkley LL , Pinkerton PH , Fastman BR , Romans RA , et al.   Reporting of near-miss events for transfusion medicine (improving transfusion safety) . Transfusion . 2001;41:1204–1211
  37. Killen AR , Beyea SC . Learning from near misses in an effort to promote patient safety . AORN J . 2002;77:423–425
  38. Centers for Medicare and Medicaid Services. Minimum Data Set Version 2.0 Manual. Available at: http://www4.cms.hhs.gov/quality/mds20/raich3.pdf; 2002 Accessed October 1, 2005.
  39. Greene SB , Williams CE , Hansen R , Crook KD , Akers R , Butler MG , et al.   Nursing home medication error quality initiative (MEQI) (January 1, 2004 to September 30, 2004) . 2004; Available at: http://www.shepscenter.unc.edu/meqiweb/meqifinal.pdf; Accessed August 15, 2005
  40. Schnelle JF , Ouslander JG , Cruise PA . Policy without technology (a barrier to improving nursing home care) . The Gerontologist . 1997;37:527–532
  41. National Quality Forum. NQF project Brief: standardizing a patient safety taxonomy. Available at: http://www.qualityforum.org/txsafetytaxonomybrief+SC504.pdf; 2004 Accessed September 25, 2005.
  42. Kaplan HS , Barach P . Incident reporting: science or protoscience? Ten years later . Qual Saf Health Care . 2002;11:144–145
  43. Buerhaus PI . Lucian Leape on the causes and prevention of errors and adverse events in health care . Image J Nurs Sch . 1999;31:281–286
  44. Department of Veterans Affairs. VA National Center for Patient Safety: creating a culture of safety. Available at: http://www.va.gov/ncps/vision.html; n.d. Accessed June 5, 2004.
  45. Coyle GA . Designing and implementing a close call reporting system . Nurs Adm Q . 2005;29:57–62
  46. American Health Quality Association Nursing home initiative shows results. Available at: http://www.ahqa.org; n.d. Accessed September 19, 2005.
  47. American Health Quality Association Nursing home culture change: improving quality of care, quality of life. Available at: http://www.ahqa.org/pub/quality/161_1058_4909.CFM; n.d. Accessed September 18, 2005.
  48. National Aeronautics and Space Administration Aviation Safety Reporting Systems. CALLBACK from NASA’s aviation safety reporting systems. Available at: http://asrs.arc.nasa.gov/callback.htm; n.d. Accessed September 25, 2005.
  49. National Aeronautics and Space Administration, Department of Veterans Affairs The patient safety reporting system. Available at: http://psrs.arc.nasa.gov/web_docs/PSRS_Brochure.pdf; 2002. Accessed September 5, 2005.
  50. Agency for Healthcare Research and Quality Web M & M: morbidity and mortality rounds on the Web. Available at: http://www.webmm.ahrq.gov/; n.d. Accessed October 5, 2005.
  51. Suresh G , Horbar JD , Plsek P , Gray J , Edwards WH , Shiono PH , et al.   Voluntary anonymous reporting of medical errors for neonatal intensive care . Pediatrics . 2004;113:1609–1618
  52. Cullen DJ , Bates DW , Small SD , Cooper JB , Nemeskal AR , Leape LL . The incident reporting system does not detect adverse drug events (a problem for quality improvement) . Jt Comm J Qual Improv . 1995;21:541–552
  53. Kobus DA , Amundson D , Moses JD , Rascona D , Gubler D . A computerized medical incident reporting system for errors in the intensive care unit (initial evaluation of interrater agreement) . Mil Med . 2001;166:350–353
  54. Affonso D , Jeffs L . Near misses (health professionals’ and consumers’ perspectives) . 2004; Paper presented at: sigma Theta Tau International 15th International Nursing Research Congress; July 22-24; Dublin, Ireland
  55. Filippi V , Brugha R , Browne E , Gohou V , Bacci A , DeBrouwere V , et al.   Obstetric audit in resource-poor settings (lessons from a multi-country project auditing ’near miss’ obstetrical emergencies) . Health Policy Plan . 2004;19:57–66
  56. Port CL . Identifying changeable barriers to family involvement in the nursing home for cognitively impaired residents . The Gerontologist . 2004;44:770–778
  57. Ebright PR , Urden L , Patterson E , Chalko B . Themes surrounding novice nurse near-miss and adverse event situations . J Nurs Adm . 2004;34:531–538

PII: S0029-6554(06)00004-2

doi: 10.1016/j.outlook.2006.01.003

Nursing Outlook
Volume 54, Issue 2 , Pages 85-93 , March 2006