Inconsistent information and incorrect monitoring also identified as causes of near misses
TUESDAY, May 31 (HealthDay News) -- Perioperative registered nurses (RNs) identify communication between the team as the most important factor responsible for near misses or close-call situations that could result in a health care error, according to a study published in the May issue of the AORN Journal.
Barbara Cohoon, Ph.D., R.N., from the National Military Family Association in Alexandria, Va., examined how RNs working in perioperative services recognize near misses, and what they perceive as the causes of these near misses. A total of 47 perioperative nurses completed up to four surveys detailing the near misses that they had personally experienced. The nurses ranked six causal factors (staff, team, task, workload, patient characteristics, and hospital characteristics) according to the extent to which they believed that factor contributed to the near miss.
Cohoon found that communication between the team was the top-ranked cause, with team factor most frequently identified as the cause of near misses. Inconsistent information and incorrect monitoring were also identified as common causes of near misses, and resulted in errors such as sponge or instrument being left in the incision, or surgery being performed on the wrong side or on the wrong patient.
"This information can be used to develop or revise health care institution policies and procedures. Further research is needed to study this problem in additional perioperative settings and in other health care settings," the author writes.
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