What is it about?

Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. We analyzed all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

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Why is it important?

Learning from patient safety incidents is a crucial step toward developing mechanisms and processes that can prevent similar events and contribute to a culture of safety.


The high number of near-miss incident reports reflects good staff adherence to the reporting system. We argue that improving safety culture is not necessarily an antecedent to or a consequence of incident reporting. Rather, there is a dynamic relationship that contributes to the establishment of a safety culture with emphasis on organizational learning.

Elisiane Lorenzini
Universidade Federal de Santa Catarina

Read the Original

This page is a summary of: Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study, International Journal of Risk & Safety in Medicine, November 2020, IOS Press,
DOI: 10.3233/jrs-194050.
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