Near miss (safety)

Last updated

A near miss, near death, near hit or close call is an unplanned event that has the potential to cause, but does not actually result in human injury, environmental or equipment damage, or an interruption to normal operation.[ citation needed ]

Contents

OSHA defines a near miss as an incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as near accidents, accident precursors, injury-free events and, in the case of moving objects, near collisions. [1] A near miss is often an error, with harm prevented by other considerations and circumstances. [2]

Causes

There are factors for a near miss related to the operator, and factors related to the context. Fatigue is an example for the former. The risk of a car crash after a more than 24h shift for physicians has been observed to increase by 168%, and the risk of near miss by 460%. [3] Factors relating to the context include time pressures, unfamiliar settings, and in the case of health care, diverse patients, and high patient-to-nurse staffing ratios. [4]

Reporting, analysis and prevention

Most safety activities are reactive and not proactive. Many organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss producing events but are largely ignored because nothing (no injury, damage or loss) happened. Employees are not enlightened to report these close calls as there has been no disruption or loss in the form of injuries or property damage. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations. In the heavy construction industry, near miss reporting software allows crews to find and document opportunities that help reduce safety risks as the software tracks, analyzes and calls attention to near misses on the job site to help prevent future incidents. [5] History has shown repeatedly that most loss producing events (accidents) were preceded by warnings or near accidents, sometimes also called close calls, narrow escapes or near hits. [6]

In terms of human lives and property damage, near misses are cheaper, zero-cost learning opportunities (compared to learning from actual injury or property loss events)

Getting a very high number of near misses is the goal as long as that number is within the organization's ability to respond and investigate - otherwise it is merely a paperwork exercise and a waste of time; it is possible to achieve a ratio of 100 near misses reported per loss event. [7]

Achieving and investigating a high ratio of near misses will find the causal factors and root causes of potential future accidents, resulting in about 95% reduction in actual losses. [7]

An ideal near miss event reporting system includes both mandatory (for incidents with high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and the factors that prevented loss from occurring.

The events that caused the near miss are subjected to root cause analysis to identify the defect in the system that resulted in the error and factors that may either amplify or ameliorate the result.[ citation needed ]

To prevent the near miss from happening again, the organization must institute teamwork training, feedback on performance and a commitment to continued data collection and analysis, a process called continuous improvement.[ citation needed ]

Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus, capturing near misses not only provides an inexpensive means of learning, but also has some equally beneficial spin offs:[ citation needed ]

Safety improvements by reports

Reporting of near misses by observers is an established error reduction technique in many industries and organizations:

Aviation

In the United States, the Aviation Safety Reporting System (ASRS) has been collecting confidential voluntary reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after TWA Flight 514 crashed on approach to Dulles International Airport near Washington, D.C., killing all 85 passengers and seven crew in 1974. The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles air traffic controllers, and that earlier another airline had told its pilots, but not other airlines, about a similar near miss. The ASRS identifies deficiencies and provides data for planning improvements to stakeholders without regulatory action. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this program. Due to near miss observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, to one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997. [9] Furthermore, according to a report in The New York Times on Wednesday, November 15, 2023 in response to a series of near collisions, the Federal Aviation Administration sought the input of external experts. The experts recommended addressing the shortage of air traffic controllers and upgrading outdated technology. [10]

In the United Kingdom, an aviation near miss report is known as an "airprox", an air proximity hazard, [11] by the Civil Aviation Authority. Since reporting began, aircraft near misses continue to decline. [12]

Fire-rescue services

The rate of fire fighter fatalities and injuries in the United States is unchanged for the last 15 years despite improvements in personal protective equipment, apparatus and a decrease in structure fires. [13] In 2005, the National Fire Fighter Near-Miss Reporting System was established, funded by grants from the U.S. Fire Administration and Fireman’s Fund Insurance Company, and endorsed by the International Associations of Fire Chiefs and Fire Fighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses, or is told of a near-miss event. The report may be anonymous, and is not forwarded to any regulatory agency. [14]

Law enforcement and public safety

A total of 1,439 U.S. law enforcement officers died in the line of duty during the past 10 years, an average of one death every 61 hours or 144 per year. There were 123 law enforcement officers killed in the line of duty in 2015. [15] In 2014, the Law Enforcement Officer (LEO) Near Miss Reporting System was established, with funding support from the U.S. Department of Justice's Office of Community Oriented Policing Services (COPS Office). [16] Since its launch, the LEO Near Miss system has established endorsements and partnerships with the National Law Enforcement Officers' Memorial Fund (NLEOMF), the International Association of Chiefs of Police (IACP), the International Association of Directors of Law Enforcement Standards and Training (IADLEST), the Officer Down Memorial Page (ODMP) and the Below 100 organization. [16] The Police Foundation, a national, independent non-profit organization, operates the system and has received additional support from the Motorola Solutions Foundation. [17] Law enforcement members are to submit voluntary reports when involved in or having witnessed or become aware of a near-miss event. Near miss reports take minutes to submit, can be submitted anonymously and are not forwarded to regulatory or investigative agencies, but are used to provide analysis, policy and training recommendations to the law enforcement community.

Healthcare

AORN, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near miss reporting system called SafetyNet covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members. [18]

The United States Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) developed the Patient Safety Reporting System modeled upon the Aviation Safety Reporting System to monitor patient safety through voluntary, confidential reports. [19]

Rail

CIRAS (the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the University of Strathclyde for use in the Scottish rail industry. However, after the Ladbroke Grove rail crash, John Prescott mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous Charitable trust. [20]

See also

Related Research Articles

<span class="mw-page-title-main">Safety</span> State of being secure from harm, injury, danger, or other non-desirable outcomes

Safety is the state of being "safe", the condition of being protected from harm or other danger. Safety can also refer to the control of recognized hazards in order to achieve an acceptable level of risk.

<span class="mw-page-title-main">Safety-critical system</span> System whose failure would be serious

A safety-critical system or life-critical system is a system whose failure or malfunction may result in one of the following outcomes:

<span class="mw-page-title-main">Aviation safety</span> State in which risks associated with aviation are at an acceptable level

Aviation safety is the study and practice of managing risks in aviation. This includes preventing aviation accidents and incidents through research, educating air travel personnel, passengers and the general public, as well as the design of aircraft and aviation infrastructure. The aviation industry is subject to significant regulation and oversight.

The Aviation Safety Reporting System, or ASRS, is the US Federal Aviation Administration's (FAA) voluntary confidential reporting system that allows pilots, air traffic controllers, cabin crew, dispatchers, maintenance technicians, ground operations, and UAS operators and drone flyers to confidentially report near misses or close call events in the interest of improving aviation safety. The ASRS collects, analyzes, and responds to voluntarily submitted aviation safety incident reports in order to reduce the likelihood of aviation accidents. The ASRS was designed and is operated by NASA, who is seen as a neutral third-party due to its lack of enforcement authority and relations with airlines. The confidential and independent nature of the ASRS is key to its long-term success in identifying numerous latent system hazards in the National Airspace System (NAS). The FAA extends limited immunity to individual aviation workers for reporting safety events which do not result in an accident, as defined by the FAA. This has the effect of encouraging these potential reporters to come forward with systemic safety issues without fear of reprisal. The success of the system stands as a positive example used as a model by other industries seeking to make improvements in safety. Other industries who have modeled similar systems on the ASRS include the rail, medical, firefighters, and off-shore petroleum production.

<span class="mw-page-title-main">Safety culture</span> Attitude, beliefs, perceptions and values that employees share in relation to risks in the workplace

Safety culture is the collection of the beliefs, perceptions and values that employees share in relation to risks within an organization, such as a workplace or community. Safety culture is a part of organizational culture, and has been described in a variety of ways; notably the National Academies of Science and the Association of Land Grant and Public Universities have published summaries on this topic in 2014 and 2016.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery

<span class="mw-page-title-main">Accident analysis</span> Process to determine the causes of accidents to prevent recurrence

Accident analysis is a process carried out in order to determine the cause or causes of an accident so as to prevent further accidents of a similar kind. It is part of accident investigation or incident investigation. These analyses may be performed by a range of experts, including forensic scientists, forensic engineers or health and safety advisers. Accident investigators, particularly those in the aircraft industry, are colloquially known as "tin-kickers". Health and safety and patient safety professionals prefer using the term "incident" in place of the term "accident". Its retrospective nature means that accident analysis is primarily an exercise of directed explanation; conducted using the theories or methods the analyst has to hand, which directs the way in which the events, aspects, or features of accident phenomena are highlighted and explained. These analyses are also invaluable in determining ways to prevent future incidents from occurring. They provide good insight by determining root causes, into what failures occurred that lead to the incident.

<span class="mw-page-title-main">Swiss cheese model</span> Model used in risk analysis

The Swiss cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of Swiss cheese, which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure. The model was originally formally propounded by James T. Reason of the University of Manchester, and has since gained widespread acceptance. It is sometimes called the "cumulative act effect".

<span class="mw-page-title-main">Tram accident</span>

A tram accident is any accident involving a tram or tram system.

The Fire Fighter Near Miss Reporting System was launched on August 12, 2005 by the International Association of Fire Chiefs. It was announced at a press conference in Denver, Colorado, after having completed a pilot program involving 38 fire departments across the country. The Near Miss Reporting System aims to prevent injuries and save lives of other firefighters by collecting, sharing and analyzing near-miss experiences. The near-miss experiences are collected by firefighters who voluntarily submit them; the reports are confidential, non-punitive, and secure. After the reports are compiled, they are posted to the website where firefighters can access them and learn from each other's real-life experiences. Overall these reports help to formulate strategies, reduce firefighter injuries and fatalities, and enhance the safety culture of the fire service. The program is based on the Aviation Safety Reporting System (ASRS), which has been gathering reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The reporting system is funded by the International Association of Fire Chiefs.

<span class="mw-page-title-main">Reporting of Injuries, Diseases and Dangerous Occurrences Regulations</span> United Kingdom legislation

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, often known by the acronym RIDDOR, is a 2013 statutory instrument of the Parliament of the United Kingdom. It regulates the statutory obligation to report deaths, injuries, diseases and "dangerous occurrences", including near misses, that take place at work or in connection with work.

<span class="mw-page-title-main">Traffic collision</span> Incident when a vehicle collides with another object

A traffic collision, also called a motor vehicle collision, occurs when a vehicle collides with another vehicle, pedestrian, animal, road debris, or other moving or stationary obstruction, such as a tree, pole or building. Traffic collisions often result in injury, disability, death, and property damage as well as financial costs to both society and the individuals involved. Road transport is the most dangerous situation people deal with on a daily basis, but casualty figures from such incidents attract less media attention than other, less frequent types of tragedy. The commonly used term car accident is increasingly falling out of favor with many government departments and organizations, with the Associated Press style guide recommending caution before using the term. Some collisions are intentional vehicle-ramming attacks, staged crashes, vehicular homicide or vehicular suicide.

<span class="mw-page-title-main">Confidential Incident Reporting & Analysis System</span> Transportation safety reporting service in the UK

The Confidential Incident Reporting & Analysis Service (CIRAS), formerly the Confidential Incident Reporting & Analysis System, is a confidential safety reporting service for health, safety and wellbeing concerns raised by workers in the UK transport industry. It is funded by members and run independently, though is a wholly owned subsidiary of Rail Safety and Standards Board (RSSB). The service covers the following sectors: passenger and freight train operators, light rail, Network Rail and its suppliers, London Underground, and Transport for London (TfL) bus operators.

<span class="mw-page-title-main">Accident</span> Unforeseen event, often with a negative outcome

An accident is an unintended, normally unwanted event that was not directly caused by humans. The term accident implies that nobody should be blamed, but the event may have been caused by unrecognized or unaddressed risks. Most researchers who study unintentional injury avoid using the term accident and focus on factors that increase risk of severe injury and that reduce injury incidence and severity. For example, when a tree falls down during a wind storm, its fall may not have been caused by humans, but the tree's type, size, health, location, or improper maintenance may have contributed to the result. Most car wrecks are not true accidents; however, English speakers started using that word in the mid-20th century as a result of media manipulation by the US automobile industry.

<span class="mw-page-title-main">Patient Safety and Quality Improvement Act</span> US law

The Patient Safety and Quality Improvement Act of 2005 (PSQIA): Pub. L.Tooltip Public Law  109–41 (text)(PDF), 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety organizations and a national patient safety database. To encourage reporting and broad discussion of adverse events, near misses, and dangerous conditions, it also established privilege and confidentiality protections for Patient Safety Work Product. The PSQIA was introduced by Sen. Jim Jeffords [I-VT]. It passed in the Senate July 21, 2005 by unanimous consent, and passed the House of Representatives on July 27, 2005, with 428 Ayes, 3 Nays, and 2 Present/Not Voting.

A safety taxonomy is a standardized set of terminologies used within the fields of safety and health care. The goal is to foster clear communication, as the terminology used within these fields can be immensely confusing, even to specialists.

Human factors are the physical or cognitive properties of individuals, or social behavior which is specific to humans, and influence functioning of technological systems as well as human-environment equilibria. The safety of underwater diving operations can be improved by reducing the frequency of human error and the consequences when it does occur. Human error can be defined as an individual's deviation from acceptable or desirable practice which culminates in undesirable or unexpected results.

Dive safety is primarily a function of four factors: the environment, equipment, individual diver performance and dive team performance. The water is a harsh and alien environment which can impose severe physical and psychological stress on a diver. The remaining factors must be controlled and coordinated so the diver can overcome the stresses imposed by the underwater environment and work safely. Diving equipment is crucial because it provides life support to the diver, but the majority of dive accidents are caused by individual diver panic and an associated degradation of the individual diver's performance. - M.A. Blumenberg, 1996

<span class="mw-page-title-main">Work-related road safety in the United States</span>

People who are driving as part of their work duties are an important road user category. First, workers themselves are at risk of road traffic injury. Contributing factors include fatigue and long work hours, delivery pressures, distractions from mobile phones and other devices, lack of training to operate the assigned vehicle, vehicle defects, use of prescription and non-prescription medications, medical conditions, and poor journey planning. Death, disability, or injury of a family wage earner due to road traffic injury, in addition to causing emotional pain and suffering, creates economic hardship for the injured worker and family members that may persist well beyond the event itself.

A confidential incident reporting system is a mechanism which allows problems in safety-critical fields such as aviation and medicine to be reported in confidence. This allows events to be reported which otherwise might not be reported through fear of blame or reprisals against the reporter. Analysis of the reported incidents can provide insight into how those events occurred, which can spur the development of measures to make the system safer.

References

  1. ↑ Howard, Keith. "Everybody gets to go home in one piece". Safety+Health. National Safety Council. Retrieved 28 June 2021.
  2. ↑ My Near Miss DANIELLE OFRI, MAY 28, 2013
  3. ↑ When Doctors Don't Sleep, Talk of the Nation, National Public Radio, 13 December 2006.
  4. ↑ Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH; Clarke; Sloane; Sochalski; Silber (2002). "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction". JAMA . 288 (16): 1987–93. doi:10.1001/jama.288.16.1987. PMID   12387650.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ↑ "Near Miss Reporting Software". HCSS. 15 December 2021. Retrieved 14 June 2022.
  6. ↑ McKinnon, Ron C. Safety Management: Near Miss Identification, Recognition, and Investigation.
  7. 1 2 "Gains from Getting Near Misses Reported" (PDF). Process Improvement Institute.{{cite journal}}: Cite journal requires |journal= (help)
  8. ↑ "Near-Miss Incident Reporting – It's About Trust". CLMI Safety Training. n.d.{{cite journal}}: Cite journal requires |journal= (help)
  9. ↑ Wald, Matthew L. (October 1, 2007). "Fatal Airplane Crashes Drop 65%". The New York Times. Retrieved 2007-10-01.
  10. ↑ Walker, Mark (2023-11-15). "Staffing and Technology Woes Threaten Aviation Safety, Report Says". The New York Times. ISSN   0362-4331 . Retrieved 2023-11-19.
  11. ↑ "Air Proximity Hazard" (PDF). Archived from the original (PDF) on August 1, 2014. Retrieved August 29, 2014.
  12. ↑ Civil Aviation Authority: UK Airprox Board Archived 2006-08-13 at the Wayback Machine , Retrieved July 16, 2006
  13. ↑ National Fire Fighter Near-Miss Reporting System (www.firefighternearmiss.com): FAQ Archived 2006-07-18 at the Wayback Machine Retrieved July 16, 2006
  14. ↑ Mandak, Joe (September 18, 2005). "Database seeks to lower firefighter deaths". USA Today. Retrieved 2006-07-08.
  15. ↑ "National Law Enforcement Officers Memorial Fund: Law Enforcement Facts". www.nleomf.org. Retrieved 2016-11-14.
  16. 1 2 "LEO Near Miss". www.leonearmiss.org. Retrieved 2016-11-14.
  17. ↑ "Police Foundation Receives Public Safety Grant Award from Motorola Solutions Foundation". www.policefoundation.org. Retrieved 2016-11-14.
  18. ↑ AORN: SafetyNet Archived 2006-07-17 at the Wayback Machine Retrieved on July 16, 2006
  19. ↑ L. A. Lenert, MD, MS, H. Burstin, MD, MPH, L. Connell, MA, RN, J. Gosbee, MD, MS, and G. Phillips (1 January 2002). "Federal Patient Safety Initiatives Panel Summary". J Am Med Inform Assoc. 9 (6 Suppl 1): s8–s10. doi:10.1197/jamia.M1217. PMC   419408 . PMID   12386172.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ↑ CIRAS Charitable Trust CIRAS website, Retrieved December 20th, 2006
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.