1. Walsall LPC AGM – Near Miss Reporting.

2. Near Miss Recording
Creating the Right Culture

3. Problems with a punitive culture
Punishment stifles reporting and learning
Reduction in patient safety and quality of care
Traditionally this approach, fast recognised as unacceptable

4. Why a no-blame culture is inadequate
No-blame culture: blanket immunity
Lack of accountability
Not acceptable to society. Unfair
Widely accepted still although lacks accountability, especially for the public.

5. We need the “right culture”
Just culture
Open culture, reporting culture, learning culture
Safety and quality culture; balanced accountability and learning
Fair working environment, improved patient experience, improved patient safety and quality of care

6. Achieving the right culture. An outline.
Commitment to the right culture
Recognising where it exists
Getting the infrastructure right
Living the right culture

7. Clinical Audit - part of NHS Contractual requirements
Why is Near Miss reporting important?
Clinical Audit - part of NHS Contractual requirements
Dispensary efficiency
Patient safety
Clinical Governance
High priority on GPhC Inspections 7

8. Triangle of Risk – the ratio of near miss to error rate
death
hospital
Police/paramedic/fire service
Body panel dented
Car park scrapes 8

9. The incident iceberg and importance of near misses and “insignificant” errors
(Smith, 2004)

10. Near Misses Through the Working Day

11. Human Factors
Human Factors in healthcare is an approach to enhancing clinical performance through an understanding of the effects that teamwork, tasks, equipment, workspace, culture and organisation have on human behaviour and abilities. “Things that make it easier to do the right things, to the best of our ability”

12. Cna Yuo Raed Tihs
fi yuo cna raed tihs, yuo hvae a sgtrane mnid too. Cna yuo raed tihs? Olny 55 plepoe out of 100 can.
i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno’t mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghi t pclae. The rset can be a taotl mses and you can sitll raed it whotuit a pboerlm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt! if you can raed tihs forwrad it.
Arocdnicg to rsceearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer are in the rghit pcale. The rset can be a toatl mses and you can sitll raed it wouthit pobelrm. Tihs is buseace the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.
They say that only 55 people out of 100 can read that way. I would believe this number to be higher (considering that I never found someone who could not read it). What do you think?

13. Spot the difference?

14. Process / procedure design
Human Factors
Equipment design
Environment design
Process / procedure design
Thinking skills
Social Skills

15. “No Blame Culture” Responses
Busy
Attention
Short staffed
No staff
Not again!
Ditto marks
Blanks
Too rushed
Which is most common? – (blanks) 15

16. Good Near Miss Action Plans
Logs shows consistent and credible data
Thought has been applied
Action plan relates to findings from the audit
Incorporates the whole picture
SMART is present
Team involvement and engagement
Action is specific to the learnings generated
There is a visible change of action and/or behaviour
Team engagement, signed, person specific
Looks at environment, people and process 16

17. Best Practice ‘Hints and Tips’
All team members should complete their own near miss records.
Learnings and actions taken should be tangible and demonstrable. Avoid ‘concentrate more’ ‘try harder’ and ‘double check’.
Review monthly and involve all team members in the review process – ownership
Consider the environment as a whole – contributing factors.
- ‘No near miss today’
Culture.