May 20, 2011 | | Comments 0
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Preceptor perspectives: Reporting a near miss event

by Julie Harris, RN, MSN

Who likes to get in trouble? I know that I sure don’t! Yet, reporting a near miss event sometimes feels like that. Let’s look at a scenario that demonstrates this feeling:

One night Mason noticed a medication error from the pharmacy. They sent up the wrong dose of medication for his patient. After sending the medication back to the pharmacy, Mason filled out an occurrence form and placed it in his manager’s box. Several days later, the manager called him into a meeting with the pharmacy and other managers. They wanted him to explain the near miss event. He did and then was excused from the remainder of the meeting. Mason left feeling like he received a slap on the hand for reporting the near miss. He wondered if he should bother reporting any other near misses in the future.

This scenario is common throughout hospitals and healthcare facilities. Mason felt like he was in trouble for reporting the near miss event.

Many nurses, like Mason, do not see the “big picture” when it comes to reporting a near miss. And many times, this is due to a lack of just culture training from the hospital. Nurses are told they have to report near miss events. But, they are not told why to report such events or the outcomes of their report.

Preceptors can help solve this problem by training orientees and other staff members on the “big picture” of near miss reporting. This training should include:

  • The importance of reporting a near miss event
  • What qualifies as a near miss event
  • How to report a near miss event (i.e. how to fill out the form)
  • Where the report goes after it leaves the nurse
  • Who to contact for follow up
  • Examples of near miss events and their outcomes involving process change, patient safety, etc.

High-quality, safe patient care is the goal for all hospitals and healthcare facilities. Reporting near miss events is one avenue for nurses, especially preceptors, to take in order to achieve this goal!

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Julie Harris About the Author: Julie Harris MSN, RN, is a nursing education specialist at Arkansas Children’s Hospital in Little Rock, AR, and develops online and classroom curriculums for nurse preceptors. Julie coordinates an acclaimed preceptor program and tele-nursing education series at her facility, and conducts a monthly preceptor workshop packed with practical tips and tools and activities to enhance learning, communication styles, and mentoring capabilities. She is the author of several published abstracts, articles, and learning courses, and the editor of the Arkansas Children's Hospital’s nursing newsletter.

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