Making the most of near misses in general practice: an analysis

INTRODUCTION

There has long been calls for the NHS to improve its learning from patient safety events.¹ These events include incidents and near misses, with a preference to learn from near misses before harm occurs. Near misses are ‘prevented patient safety incidents’¹ and the authors of this analysis see them as events that, if left to progress, could result in harm to a patient. That progression is interrupted or recovered by something, or somebody (Figure 1).

Near misses are ‘free lessons’ because they generally do not result in harm and do not have the same moral burden as incidents. The academic literature provides evidence of where near misses have been identified, analysed, and learnt from in health care. For example, Adelman et al² reviewed ‘retraction and reorder’ near misses in digital ordering systems and implemented technological changes resulting in a significant reduction in the odds of wrong patient orders.

Despite calls for the NHS to improve learning from near misses, including in general practice,¹ there has been slow progress in the past 20 years.³ It is unclear whether and how general practices learn from near misses. This analysis therefore seeks to summarise the current state of near misses in general practice in the NHS in England. This analysis is informed by the experiences of practices, and provides reflections supported by the …