Navigating a Near Miss

When my daughter was around 5 years old, she disappeared.

We were outside, my wife and I doing some work around the house, and our 5-year-old playing on the driveway. She was deeply engrossed in some colored chalk, creating an infinite hopscotch board. I stepped inside to grab something, and my wife went to grab something else on the side of the house. We both returned to the driveway to find chalk rolling down towards the sidewalk – and no daughter.

She couldn’t have run into the house; that’s where I was. Nor the backyard, where my wife had been. We call her name, look around, and then realize she must have run off down the sidewalk. But we don’t see her.

Images flash by. She runs into the street and gets struck by a car. She turns towards a backyard and vanishes in the next neighborhood. She hides behind a house and never comes out.

The next image is the true sight of her running back to our house as happy as she can be. Smiling and then confused because her parents are sweating and yelling, and she has no idea she did anything wrong. I have to talk my wife down from researching GPS chips for kids.

There are those moments almost every day as a parent: almost fell down the stairs, or almost falling off the swing, or jumping on the bed, then off the bed and almost landing on her head. The land of daily almosts, close calls.

Last month, our life in the Clearwater Beach area seemed that it was going be in the center of Hurricane Irma.

After days of showing the path off towards the east, the day before landfall, the map showed our county right in the bullseye. After several days of deliberation, watching the spaghetti models, and trafficking in amateur meteorology, a late storm wobble forced the next step. My wife, kids, and dog headed out of town before the sunrise. I rode the storm out in the hospital after saying goodbye to my house in the morning. We were in the middle of the path the day Irma was to hit. I would see a patient, refresh noaa.gov, try another weather site with a better cone of doom, see a patient, share in the dread with them. The dead center hit to this area and the potential storm surge didn’t come – a glancing blow with many tough situations, but no Category 4 devastation.

As that near miss lingers, I am reminded of the ones we all face daily in the hospital. Every day, a close call of some type seems to abound. I will get a call from the pharmacist about the anticoagulation I ordered, confirming the order, only for them to ask me if I’m sure I want that enoxaparin now since Apixaban is ordered as well. Or when I ordered a stat dose, to be reminded that the patient received a full dose of enoxaparin about an hour ago in the ER. Those close calls are thankfully caught by the pharmacist. They were sometimes simply oversights on my part – not recognizing that other anticoagulant on the home medication list or being told no anticoagulant was started for the PE in the ER, so I ordered a dose, but then find out that Lovenox was given in the ER, but recorded after I was in the chart placing my order. And on and on.

In the hospital, medication errors, diagnostic misses, and communication lapses seem like daily occurrences. The phrase “near miss” is a misnomer. These scenarios are often true misses; my daughter didn’t disappear, and that patient didn’t get the Lovenox on top of the Apixaban. They were good catches, saves, close calls, or sometimes just dumb luck.

It is essential to be mindful of their occurrence, recognizing we can learn from a near miss as we can from a true error or adverse event. For one, they are more plentiful; they are the unseen layers of error from which the most valuable lessons can be learned.

Near misses are important for a number of reasons:

  1. They occur more frequently than reported errors.
  2. Near misses are easier to talk about then true adverse events. They are less emotionally charged.
  3. If captured, they can be studied in real time.

Given their importance, they should be identified and discussed in the hospital. The first step is to have a clear, easy-to-use reporting system, generally online, that allows for easy submissions. This reporting system needs to exist in a just culture. Ideally, you are in a health system that encourages error reporting, rewards people for reporting near misses and errors, and comfortably discusses error in the vein of continuous improvement.

Near misses should have a process similar to adverse events. They need to properly identified and recorded. Subsequently, a detailed investigation, ideally in real time, can occur, that will be provided to a patient safety committee or similar group. That committee will discuss the incident, assign a priority, and provide appropriate follow up. Near misses are our daily bread, and in an imperfect world, they can be the lessons heeded to grow to a more perfect healthcare environment.

We are still trying to process the near miss from Irma.

Unfortunately, the hurricane that blew through – our near miss – is someone else’s hit. It’s like the 50-year-old who I reassure that mass was benign at 8AM, yet by noon, I tell someone who looks just like him that the pancreatic lesion is cancerous.

The near miss from Irma for us was destructive for other communities. In our community, we are trying to find ways to support the challenges in Puerto Rico. This website provides ongoing dashboard of what services are back online, in real time showing the true struggles on the ground, and here are some suggestions on where to help for Puerto Rico, victims of Harvey, or Irma.

Hurricanes Maria, Irma, and Harvey weren’t near misses for many. Yet, for those that experience that close call, it’s time to heed the warning as we should for the same type of events in the hospital.

I learned that preparation for a hurricane and an evacuation plan is paramount, and will work towards having a better plan to track near misses in our hospital, and most importantly will reconsider that tracking chip for our daughter.

We are more prepared for the next hurricane, and even without the hit, more mindful of what is happening elsewhere when the Category 4-5 does strike. That could have been us. We will come out from the near miss hopefully better prepared – in our household, in our hospital, in our community. Some will heed the lessons better than others. We hopefully learn from our mistakes, take note, prepare better, see what went wrong, and what we can improve.

For more on near misses, check out:

  1. Wu AW, ed. The Value of Close Calls in Improving Patient Safety. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158.
  2. https://psnet.ahrq.gov/webmm/case/254#references
  3. https://www.ncbi.nlm.nih.gov/pubmed/26126125
Jordan Messler

Jordan is a hospitalist at Morton Plant Hospitalists in Clearwater, Florida. He currently chairs SHM’s Quality and Patient Safety Committee. In addition, he’s been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. He went to medical school at University of South Florida, in Tampa, and completed his residency at Emory University.

He recognizes the challenges of working in a hospital that lines the intracostal waterways of a spring break mecca. Requests that if you want to be selected as a mentored site, you will have a similar location with palm trees and coastline nearby. He tries to find time to sit on the beach with his family to escape the hospital’s miasma. While there, he looks forward to reading about the history of hospitals/medicine, and how it relates to quality (Anti-UpToDate reading material). But inevitably will get a five year old dumping sand on him, and then has to explain why she is buried up to her neck.

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