near miss event

A near miss event is an event for which unwanted consequences were prevented because some recovery action was taken that identified and corrected the failure.

Recovery actions, which are present in all near miss events, can be planned or unplanned. The recovery is planned if it results from a barrier, such as a check point in the work process, that was designed to catch mistakes or ensure quality. However, the recovery is unplanned if it results from an accidental or lucky catch.

MERS-TM categorizes events into three types: misadventures, no harm events, and near miss events.
Near miss events are valued as important sources of information because their numbers are great (See iceberg model) and they share characteristics of actual events with negative outcomes. Determining trends in the occurrences of near misses can result in effective countermeasures to prevent potential future misadventures.

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no harm event

A no harm event is an event that has actually occurred (no recovery action was taken) but where no actual harm has come to the patient or the organization. Except for "luck" (or in health care, the robust nature of human physiology), these accidents would have become misadventures.

As shown by the iceberg model, no harm events receive less attention than misadventures but are numerous enough to provide a valuable source of information about events within an organization.

MERS-TM categorizes events into three types: misadventures, no harm events, and near miss events.

List of Terms

punitive culture

In the field of health care punishment is often used as a negative incentive in an attempt to attain perfect performance and thus eliminate events. This type of work environment is called a "punitive" culture.

Although punishment as a motivational tool has been the traditional approach in medicine, this emphasis on perfection has several potential adverse consequences.

In a punitive culture there will be scant reporting of human error because it is "illegal" and employees choose to hide their mistakes in an effort to protect their jobs. Because of the focus on the individual, a common response within a blaming or punitive culture is to make re-training the major corrective action, ignoring the relevance of other contributing factors.

One serious consequence is that focusing only on human performance issues and blaming the individuals involved obscures the opportunity to identify underlying latent conditions contributing to the event. The opportunity for learning from and possibly preventing events is lost.

List of Terms