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Reporting, Investigation & Learning from Near Miss Incidents

Friday 30 November 2018
De Vere West One Conference Centre,, London

Reporting, Investigation & Learning from Near Miss Incidents

This event has now past, but there may well be news on the event including presentations and quotes from the day at our News pages here, a full list of our forthcoming events is available here.

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‘When things go wrong in care, it is vital incidents are recorded to ensure learning can take place. By learning, we mean people working out what has gone wrong and why it has gone wrong, so that effective and sustainable actions are then taken locally to reduce the risk of similar incidents occurring again.’ NHS England

A Near Miss Incident is an incident where an event or an omission does not develop further to cause actual harm - but did have the realistic potential to do so. Near-misses are free lessons and are as important in terms of the way lessons are learned as those events where actual harm has occurred. Reporting, investigation and learning from near miss incidents can reduce the potential for the event to recur in the future. It is also important to understand, learn from and replicate the intervention that prevented the near miss from leading to harm; understanding the barriers, staff intervention or situational awareness that led to the near miss being recognised and more serious consequences avoided.

‘We encourage all users to review their own patient safety incidents to understand more about their reporting culture and areas where local improvements in safety culture and patient safety can be made…The degree of harm helps us learn about the impact of incidents on patients and identify those incidents causing most harm... Clinical review uses NRLS data to identify new or emerging issues that may need national action, such as a patient safety alert…. Sometimes reporters give an incident’s potential degree of harm instead. For example, the resulting degree of harm is occasionally coded as ‘severe’ for ‘near miss’ where no harm resulted as the impact was prevented. This should be considered when interpreting the degree of harm.’ NRLS March 2018

‘It may be appropriate for a ‘near miss’ to be a classed as a serious incident because the outcome of an incident does not always reflect the potential severity of harm that could be caused should the incident (or a similar incident) occur again. Deciding whether or not a ‘near miss’ should be classified as a serious incident should therefore be based on an assessment of risk that considers: The likelihood of the incident occurring again if current systems/process remain unchanged; and o The potential for harm to staff, patients, and the organisation should the incident occur again.’ Serious Incident Framework, NHS England

‘We believe the most effective learning can be drawn from thorough investigations and produce meaningful recommendations that are shared at a wider level. By not attributing blame or liability, asking the right questions, and gaining different perspectives we can reduce the risk of something similar happening in the future.’ Healthcare Safety Investigations Branch 2018

This conference will enable you to:

  • Network with colleagues who are working to improve the identification, investigation and learning from near miss incidents
  • Learn from outstanding practice in near miss reporting and investigation
  • Reflect on national developments in patient safety investigation
  • Improve the way near misses are investigated in your service
  • Develop your skills in recognizing the barriers that prevented the near miss from leading to harm
  • Understand how you can improve staff situational awareness and anticipation of near miss potential
  • Identify key strategies for involving families and carers
  • Understand when near misses should be considered as serious incidents
  • Use triangulation and analysis of patient safety data to inform patient safety trends
  • Self-assess and reflect on your own practice
  • Gain CPD accreditation points contributing to professional development and revalidation evidence

100% of delegates at our previous conference on this subject would recommend it to a colleagues

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