Causes of Near Misses: Perceptions of Perioperative Nurses

The purpose of this study was to examine the near-miss experiences of RNs working in perioperative services to understand their perception of the causes of near misses. The setting was a multi-facility health care system in the mid-Atlantic region of the United States. The study design was descriptive, using a survey of perioperative nurses that was developed for the study. Study participants could complete up to four surveys for near misses that they personally experienced in the perioperative setting. Participants ranked six causal factors (ie, team, workload, task, staff, patient characteristics, hospital characteristics) according to the extent of that factor's contribution to the near miss. The team factor was the most frequently identified cause of near misses, with the top ranked cause as “communication between team.” Two causal factor subcategories, “inconsistent information” and “incorrect monitoring,” were predominant in the near misses reported. The findings from the study provide an understanding of perioperative nurses' near-miss experiences and detail the frequency of near misses as well as identify types of near-miss causes.