Near miss (safety)
Encyclopedia
See Close Call
, for the 2002 film.
A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near. Although the label of 'human error' is commonly applied to an initiating event, a faulty process or system invariably permits or compounds the harm, and should be the focus of improvement. Other familiar terms for these events is a "close call", or in the case of moving objects, "near collision".
- Captures sufficient data for statistical analysis; trending studies.
- Provides immense opportunity for "employee participation," a basic requirement for a successful EHS Program. This embodies principles of behavior shift, responsibility sharing, awareness, and incentives.
- One of the primary workplace problems Near Miss incident reporting attempts to solve directly or indirectly is to try to create an open culture whereby everyone shares and contributes in a responsible manner. Near-Miss reporting has been shown to increase employee relationships and encourage teamwork in creating a safer work environment.
Close Call
Close Call is a 2002 crime-drama film directed by Jimmy Lee. The movie is about Jenny Kim, a 16-year-old Korean American who is caught in an underground world of crimes, drugs and sex....
, for the 2002 film.
A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near. Although the label of 'human error' is commonly applied to an initiating event, a faulty process or system invariably permits or compounds the harm, and should be the focus of improvement. Other familiar terms for these events is a "close call", or in the case of moving objects, "near collision".
Reporting, Analysis and Prevention
Most safety activities are reactive and not proactive. Many organizations wait for losses to occur before taking steps to prevent a recurrence. Near miss incidents often precede loss producing events but are largely ignored because nothing (no injury, damage or loss) happened. Employees are not enlightened to report these close calls as there has been no disruption or loss in the form of injuries or property damage. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and reporting near miss incidents can make a major difference to the safety of workers within organizations. History has shown repeatedly that most loss producing events (accidents) were proceeded by warnings or near accidents, sometimes also called close calls, narrow escapes or near hits.- In terms of human lives and property damage, near misses are cheaper, zero-cost learning tools for safety than actual injury or property loss.
- An ideal near miss event reporting system includes both mandatory (for incidents with high loss potential) and voluntary, non-punitive reporting by witnesses. A key to any near miss report is the "lesson learned". Near miss reporters can describe what they observed of the beginning of the event, and the factors that prevented loss from occurring.
- The events that caused the near miss are subjected to root cause analysisRoot cause analysisRoot cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
to identify the defect in the system that resulted in the errorErrorThe word error entails different meanings and usages relative to how it is conceptually applied. The concrete meaning of the Latin word "error" is "wandering" or "straying". Unlike an illusion, an error or a mistake can sometimes be dispelled through knowledge...
and factors that may either amplify or ameliorate the result.
- To prevent the near miss from happening again, the organization must institute teamwork training, feedback on performance and a commitment to continued data collection and analysis, a process called continuous improvement.
- Near misses are smaller in scale, relatively simpler to analyze and easier to resolve. Thus, capturing near misses not only provides an inexpensive means of learning, but also has some equally beneficial spin offs.
- Captures sufficient data for statistical analysis; trending studies.
- Provides immense opportunity for "employee participation," a basic requirement for a successful EHS Program. This embodies principles of behavior shift, responsibility sharing, awareness, and incentives.
- One of the primary workplace problems Near Miss incident reporting attempts to solve directly or indirectly is to try to create an open culture whereby everyone shares and contributes in a responsible manner. Near-Miss reporting has been shown to increase employee relationships and encourage teamwork in creating a safer work environment.
Safety improvements by reports
Reporting of near misses by observers is an established error reduction technique in many industries and organizations:Aviation
- In the United States, the Aviation Safety Reporting SystemAviation Safety Reporting SystemThe Aviation Safety Reporting System, or ASRS, is the US Federal Aviation Administration's voluntary system that allows pilots and other airplane crew members to confidentially report near misses and close calls in the interest of improving air safety...
(ASRS) has been collecting confidential voluntary reports of close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after TWA Flight 514TWA Flight 514TWA Flight 514, registration N54328, was a Boeing 727-231 en route from Indianapolis, Indiana, and Columbus, Ohio, to Washington Dulles International that crashed into Mount Weather, Virginia, on December 1, 1974. All 85 passengers and 7 crew members were killed.The flight was originally destined...
crashed on approach to Dulles International Airport near Washington, D.C., killing all 85 passengers and seven crew in 1974. The investigation that followed found that the pilot misunderstood an ambiguous response from the Dulles air traffic controllers, and that earlier another airline had told its pilots, but not other airlines, about a similar near miss. The ASRS identifies deficiencies and provides data for planning improvements to stakeholders without regulatory action. Some familiar safety rules, such as turning off electronic devices that can interfere with navigation equipment, are a result of this program. Due to near miss observations and other technological improvements, the rate of fatal accidents has dropped about 65 percent, to one fatal accident in about 4.5 million departures, from one in nearly 2 million in 1997. - In the United Kingdom, an aviation near miss report is known as an "airprox", by the Civil Aviation Authority. Since reporting began, aircraft near misses continue to decline.
Fire-rescue services
- The rate of fire fighter fatalities and injuries in the United States is unchanged for the last 15 years despite improvements in personal protective equipment, apparatus and a decrease in structure fires. In 2005, the National Fire Fighter Near-Miss Reporting SystemNational Fire Fighter Near-Miss Reporting SystemThe National Fire Fighter Near-Miss Reporting System was launched on August 12th 2005 by the International Association of Fire Chiefs. It was announced at a press conference in Denver, Colorado, after having completed a pilot program involving 38 fire departments across the country...
was established, funded by grants from the U.S. Fire Administration and Fireman’s Fund Insurance Company, and endorsed by the International Associations of Fire Chiefs and Fire Fighters. Any member of the fire service community is encouraged to submit a report when he/she is involved in, witnesses, or is told of a near-miss event. The report may be anonymous, and is not forwarded to any regulatory agency.
Healthcare
- AORN, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near miss reporting system (SafetyNet ), covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members.
- The Patient Safety Reporting System (PSRS) is a program modeled upon the Aviation Safety Reporting System and developed by the United States Department of Veterans AffairsUnited States Department of Veterans AffairsThe United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
(VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. - The Near Miss Registry is a risk free, anonymous reporting tool for near misses in Internal Medicine. It is sponsored by the New York State Department of Health and administered by the New York Chapter of the American College of Physicians. This tool collects information about both near miss medical errors and the barriers that kept these errors from reaching patients.
Rail
- CIRAS (the Confidential Incident Reporting and Analysis System) is a confidential reporting system modelled upon ASRS and originally developed by the University of StrathclydeUniversity of StrathclydeThe University of Strathclyde , Glasgow, Scotland, is Glasgow's second university by age, founded in 1796, and receiving its Royal Charter in 1964 as the UK's first technological university...
for use in the Scottish rail industry. However, after the Ladbroke Grove rail crashLadbroke Grove rail crashThe Ladbroke Grove Rail Crash was a rail accident which occurred on 5 October 1999 at Ladbroke Grove, London, England. Thirty-one people were killed and more than 520 injured...
, John PrescottJohn PrescottJohn Leslie Prescott, Baron Prescott is a British politician who was Deputy Prime Minister of the United Kingdom from 1997 to 2007. Born in Prestatyn, Wales, he represented Hull East as the Labour Member of Parliament from 1970 to 2010...
mandated its use throughout the whole UK rail industry. Since 2006 CIRAS has been run by an autonomous Charitable trust.
See also
- Air safetyAir safetyAir safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...
- ErrorErrorThe word error entails different meanings and usages relative to how it is conceptually applied. The concrete meaning of the Latin word "error" is "wandering" or "straying". Unlike an illusion, an error or a mistake can sometimes be dispelled through knowledge...
- Hazard analysisHazard analysisA hazard analysis is used as the first step in a process used to assess risk. The result of a hazard analysis is the identification of risks. Preliminary risk levels can be provided in the hazard analysis. The validation, more precise prediction and acceptance of risk is determined in the Risk...
- Maternal near missMaternal near missA maternal near miss is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criteria of choice for evaluating women’s health and the quality of obstetric care...
- Patient safetyPatient safetyPatient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
- Road-traffic safetyRoad-traffic safetyThe term road traffic safety is about the risk of a person being killed or seriously injured while using the road network as a pedestrian, cyclist, motorist or user of on road public transport...
- Root causeRoot causeA root cause is rarely an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is misused to describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome.In...
- Root cause analysisRoot cause analysisRoot cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
- Safety engineeringSafety engineeringSafety engineering is an applied science strongly related to systems engineering / industrial engineering and the subset System Safety Engineering...
- Separation (air traffic control)Separation (air traffic control)In air traffic control, separation is the name for the concept of keeping an aircraft outside a minimum distance from another aircraft to reduce the risk of those aircraft colliding, as well as prevent accidents due to wake turbulence....