Incidents that would have led to an adverse event if it hadn’t been for luck or early detection far outnumber adverse events themselves. They also provide important learning opportunities.
Some experts consider near misses to be as important as adverse events for identifying unsafe conditions and implementing safety improvements. However, reporting of near misses is scattershot. Some organizations require or encourage staff members to report near misses, but clinicians may be reluctant to do so for various reasons including time and fear of punishment.