Characteristics of recovery from near misses in primary health care nursing: A Prospective descriptive study

Abstract

Aim: To describe the frequency and types of near misses and the recovery strategies employed by nurses in primary health care.

Background: Insufficient data are available on the role of nurses in near miss events and related factors in primary health care.

Method: A prospective descriptive study was carried out at one Urban Primary Health Care Centre, within the Málaga-Guadalhorce Health District (Malaga, Spain), from January to December 2018. Four of the ten nurses volunteered to take part.

Results: The nurses recovered 185 near misses, prevailing administrative or communication-related errors, followed by medication-related errors. No near misses were reported on the centre's anonymous error information platform.

Conclusions: A significant number of near misses occurred which could have been avoided with better communication among health care personnel. A striking finding is the failure to inform the health centre, which suggests that improvements in safety culture are needed.

Implications for nursing management: It is the responsibility and the duty of nursing management to be aware of the characteristics and frequency of near misses in primary health care, to implement strategies for improvement and to foster a culture in which the necessary information on actual or potential errors is supplied.