Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
BMJ Qual Saf. 2012 Apr;21(4):287-94. doi: 10.1136/bmjqs-2011-000256. Epub 2012 Feb 22.
The extent to which individuals in healthcare use near misses as learning opportunities remains poorly understood. Thus, an exploratory study was conducted to gain insight into the nature of, and contributing factors to, organisational learning from near misses in clinical practice.
A constructivist grounded theory approach was employed which included semi-structured interviews with 24 participants (16 clinicians and 8 administrators) from a large teaching hospital in Canada.
This study revealed three scenarios for the responses to near misses, the most common involved 'doing a quick fix' where clinicians recognised and corrected an error with no further action. The second scenario consisted of reporting near misses but not hearing back from management, which some participants characterised as 'going into a black hole'. The third scenario was 'closing off the Swiss-cheese holes', in which a reported near miss generated corrective action at an organisational level. Explanations for 'doing a quick fix' included the pervasiveness of near misses that cause no harm and fear associated with reporting the near miss. 'Going into a black hole' reflected managers' focus on operational duties and events that harmed patients. 'Closing off the Swiss-cheese holes' occurred when managers perceived substantial potential for harm and preventability. Where learning was perceived to occur, leaders played a pivotal role in encouraging near-miss reporting.
To optimise learning, organisations will need to determine which near misses are appropriate to be responded to as 'quick fixes' and which ones require further action at the unit and corporate levels.
医疗保健人员将接近差错作为学习机会的程度仍未得到充分理解。因此，进行了一项探索性研究，以深入了解临床实践中从接近差错中进行组织学习的性质和促成因素。
采用建构主义扎根理论方法，对来自加拿大一所大型教学医院的 24 名参与者（16 名临床医生和 8 名管理人员）进行了半结构化访谈。
本研究揭示了接近差错反应的三种情况，最常见的是“快速修复”，临床医生识别并纠正错误而无需采取进一步行动。第二种情况是报告接近差错但未收到管理层的反馈，一些参与者将其描述为“进入黑洞”。第三种情况是“关闭瑞士奶酪孔”，其中报告的接近差错在组织层面产生了纠正措施。“快速修复”的解释包括普遍存在的不会造成伤害的接近差错和与报告接近差错相关的恐惧。“进入黑洞”反映了管理者对运营职责和伤害患者的事件的关注。“关闭瑞士奶酪孔”发生在管理者感知到实质性的潜在伤害和可预防的可能性时。在感知到学习发生的地方，领导者在鼓励报告接近差错方面发挥了关键作用。
为了优化学习，组织将需要确定哪些接近差错适合作为“快速修复”进行响应，哪些需要在单位和公司层面采取进一步行动。
