Understanding Patient Safety: Adverse Events, Near Misses, and Errors

Patient safety is a critical aspect of healthcare that involves identifying, understanding, and mitigating risks to prevent harm to patients. Among the key concepts in this field are adverse events, near misses, and errors—terms that describe different types of patient incidents with varying implications for safety and quality improvement. Grasping these definitions and their nuances helps healthcare professionals develop effective strategies to enhance care delivery and reduce harm.

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Background

Definitions and Types of Patient Harm

An adverse event is commonly defined as an injury caused by medical management rather than the underlying illness, which results in prolonged hospitalization, disability at discharge, or both. For example, the Harvard Medical Practice Study described an adverse event as an injury directly linked to medical care that leads to additional monitoring, treatment, or death. The Institute for Healthcare Improvement echoes this, emphasizing unintended physical injuries stemming from healthcare processes that require further intervention.

Adverse events can be classified as preventable or nonpreventable. Preventable adverse events are those that could have been avoided through available means, typically falling below the standard of care expected within the community. Conversely, nonpreventable adverse events are incidents that occur despite adhering to standard protocols, often due to inherent risks in medical procedures. These distinctions were central to studies like the Medical Insurance Feasibility Study and the Harvard Medical Practice Study.

Examples illustrate these categories:

• In one case, a patient undergoing angiography for coronary artery disease suffered an embolic stroke despite standard procedure and no apparent negligence. This was considered an adverse event caused by medical management but not due to error.
• Another case involved a patient with rectal bleeding initially misdiagnosed due to limited diagnostic procedures. The delay in diagnosing colon cancer was deemed a preventable adverse event linked to substandard care, ultimately leading to advanced disease.

A related concept is the ameliorable adverse event—a term introduced in postdischarge studies—referring to injuries that, although not preventable, could have been less severe with different management actions. For instance, a patient discharged on diuretics for heart failure might develop kidney injury due to inadequate follow-up. If earlier interventions or testing had been arranged, the injury’s severity could have been significantly reduced.

Beyond preventable incidents, healthcare providers also encounter errors, which involve acts of commission (doing something wrong) or omission (failing to do the right thing). These errors can lead to adverse events or near misses. For example, a medication administered to the wrong patient constitutes an error with the potential for harm but may be caught before injury occurs, classified as a near miss.

A near miss is an event that could have caused harm but was prevented by chance or early detection. An example is a nurse mistakenly giving medication to the wrong patient, but the error is identified before any injury occurs. Such incidents highlight vulnerabilities in the system and the importance of vigilant safety protocols.

Controversies

Assessing adverse events involves a meticulous review process whereby patient charts are independently examined by experienced clinicians. However, agreement among reviewers about whether an adverse event occurred and whether it was preventable is often moderate, reflecting the subjectivity inherent in these judgments. Deciding if an event was preventable depends on current evidence, available prevention strategies, and their feasibility. As the science of patient safety advances, perceptions evolve—what was once considered unavoidable may now be deemed preventable. For instance, the introduction of bundles like the central line protocol has shifted opinions, making certain infections more clearly preventable.

Summary

In essence, adverse events are harms resulting from medical care, not the underlying disease. Critical subcategories include:

• Preventable adverse events: incidents caused by errors or failure to follow established prevention methods.
• Ameliorable adverse events: injuries that, while unavoidable, could have been less severe with different care actions.
• Adverse events due to negligence: harms stemming from care that falls below the accepted standards within the community.

There are also hazards that do not cause harm but pose risks to patient safety:

• Near misses: unsafe situations that, by chance or early intervention, do not result in harm.
• Errors: acts of commission or omission that create potential hazards, often identifiable before harm occurs.

Enhancing patient safety requires continuous monitoring, transparent reporting, and adopting advanced safety systems. For example, implementing robust healthcare safety protocols and fostering a culture of safety can significantly reduce adverse events. Recognizing and learning from near misses enables healthcare teams to address systemic vulnerabilities proactively and prevent future harm.

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