Importance of near misses

doi:10.1136/bmj.b3032

Published 28 July 2009, doi:10.1136/bmj.b3032
Cite this as: BMJ 2009;339:b3032

Letters

Patient safety

Importance of near misses

The first 150 words of the full text of this article appear below.

The sixth report of the government committee on patient safetyemphasises serious events such as the case of Wayne Jowett,who received a fatal injection of an anticancer drug at thewrong site.¹ However, less than 30% of adverse events resultin death or severe injury.² Common and minor events should betaken seriously—the iceberg analogy may be appropriatefor the burden of morbidity lying below the surface.

The root causes of all adverse events, including near misses,show the same underlying patterns of failure. High reliabilityindustries such as the aviation industry treat near misses andminor adverse events as rigorously as those that result in deathor permanent disability. By addressing near misses and minoradverse events, the underlying causes can be corrected beforethey lead to a disastrous incident.³

The report states that samples of patients’ case notesshould be systematically and periodically reviewed to recorddata . . . [Full text of this article]

Benjamin W Lamb, clinical research fellow¹, Kamal Nagpal, clinical research fellow¹

¹ Imperial College London, London W2 1PG

benjamin.lamb@imperial.ac.uk