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Reporting near-miss events in nursing homes
Authors:Wagner Laura M  Capezuti Elizabeth  Ouslander Joseph G
Affiliation:Baycrest Centre of Geriatric Care, Kunin-Lunenfeld Applied Research Unit, Toronto, ON, Canada. lwagner@klaru-baycrest.on.ca
Abstract:Since the Institute of Medicine report To Err Is Human was published in 1999, improving patient safety has become a major initiative for nurses working in all care settings. Nursing homes are a fertile environment for both a high frequency of adverse events to occur and a high number of institutional barriers to reporting them. This article outlines the barriers to reporting adverse events in nursing homes and provides support for why reporting near-miss events can serve as a means of reducing these barriers. It also provides recommendations and specific strategies for how to implement near-miss reporting systems in nursing homes such as policy changes, supportive leadership, and educating nurses about near-miss events. Further nursing research in this evolving area of patient safety is warranted.
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