Near misses and great saves are probable adverse events that never happened because the error was discovered prior to action being taken. Below are examples of three near misses or great saves, where harm to the patient was averted due to quick action by a member of the team, by a team member speaking out to advocate for the patient or just by sheer luck.
A critical care nurse responds to a Code Blue on another unit. When she arrives, she notes that the patient has a yellow DNR arm band so she instructs all to stand down. The nurse caring for the patient returns to the room with the patient’s Medical Record and notices that nothing is happening. When told the reason, she states that this patient is a full code and the Code Blue is resumed. The patient makes a full recovery.
The nurse on the telemetry unit has admitted a patient who has been made a DNR by the physician based on the patient’s request and advance directive. The nurse heads to the patient’s bedside to place the yellow arm band and is interrupted. She places the armband in her pocket and addresses several other patient care needs. She suddenly remembers the arm band when she hears a rapid response called for the patient’s room. As care is provided for the patient, the nurse follows the hospital policy for placing the arm band and making the patient a DNR. The interventions of the Rapid Response Team were not effective and the patient stops breathing and becomes pulseless. The patient’s self-determination wishes were respected and the patient was not resuscitated.
During the admission registration process, the code status for the patient is never address nor is an advance directive requested per policy. The admission nurse also does not address. The patient is later found in the bed unresponsive, a Code Blue is called and the patient is successfully resuscitated. No one in the room is sure of the patient’s code status since it was never addressed but the team decides to fully resuscitate in the absence of the needed information. After the incident, it was discovered that the patient’s wishes were to be resuscitated.
Clearly, there were opportunities for performance improvement in each of these examples even though harm did not reach the patient (in this instance, harm can be defined as a violation of the patient’s right of self-determination). Further, since all of these examples occurred in one facility, there is truly a process and systems issue throughout the facility concerning patients’ rights to self-determination.
Much can be learned by reviewing near misses and great saves but unfortunately most go unreported. In the above examples, it is clear that the facility does not have a good process in place to ensure accurate and timely code status. However, this would never become apparent to the Risk Manager or Quality Director if these near misses were not reported and a trend established. It is imperative that nurses and other healthcare providers submit occurrence reports on near misses/great saves; as well as, on actual adverse events so all can learn from what happened or could have happened. Thankfully, there are far more near misses then actual events but also far more opportunities to improve processes, systems and performance if identified and analyzed. Nurse leaders at all levels have a pivotal role in promoting and sustaining a just culture of safety that encourages and rewards reporting of all events or near events for analysis of opportunities for improvement.
