Introduction
The World Health Organization (WHO) defines a near-miss as an error that
has the potential to cause an adverse event (patient harm) but fails to
do so due to chance or because it is intercepted (1). There is a
relationship between adverse events and near-misses because, according
to Heinrich’s Law, “for every adverse event, there are 30 minor
injuries and 300 near-misses” (2). Near-misses are considered red flags
for future adverse events, offering an opportunity to analyse and
address causal factors (3).
Most high-income and several middle-income countries have implemented
national-level near-miss reporting systems that routinely collect
relevant data from hospitals (4). However, recent research identified
few countries in the South and Southeast Asian regions with these
systems in place (5). Sri Lanka does not have a comprehensive, holistic
national-level near-miss reporting system other than for the specific
issues of maternal near-misses (managed by the Family Health Bureau
(FHB) and near-misses related to blood transfusion (managed by the
National Blood Transfusion Services (NBTS) (6). Limited research has
been conducted regarding near-misses in Sri Lanka, confined solely to
maternal near-misses (7).
This interventional study, supported by the Sri Lankan Ministry of
Health, had the following objectives: 1) explore gaps in the current
issue-specific near-miss reporting systems; 2) use this information to
develop a more comprehensive, holistic, and effective system; and 3)
encourage healthcare professionals to report near-misses and take
actions to prevent their recurrence in the future. The overarching aim
was to strengthen the structures and processes used for reporting
near-misses in Sri Lanka and, in doing so, advance the national quality
and safety agenda.