Thematic Analysis of Consultative Meetings
Several key issues were identified as the major bottlenecks in the
current systems, including inadequate HCW knowledge about near-misses
and adverse events/incidents; negative perceptions of HCWs about
near-misses, adverse events/incidents, and reporting processes; poor
user-friendliness of the existing near-miss reporting systems; and a
lack of a well-established mechanism to incorporate preventive measures
as best practices to be implemented across all healthcare institutions.
The major gaps identified were that the existing near-miss reporting
systems in Sri Lanka covered only maternal near-misses or those related
to blood transfusions and that the current reporting forms were not
user-friendly.