Abstract and Key Words
Background: Near-misses are errors that have the potential to cause an
adverse event but fail to do so because of chance or because they are
intercepted. By 2021, Sri Lanka had only established systems for
maternal and blood transfusion services.
Methods: A new, holistic near-miss reporting system was developed and
piloted at a large tertiary hospital in 2022 to guide subsequent
nationwide implementation. During the pre-interventional phase,
national-level consultative meetings (n=20), key informant interviews
(n=10) and focus groups (n=22) were convened with purposively selected
representatives of professional colleges, academia, medical
administrators, and senior staff of the participating hospital to
identify existing methods of reporting near-misses. A near-miss
reporting format and guidelines were designed with input from
national-level consultative meetings. Training on the new system for
medical and nursing officers, periodic reminders to staff, and
dissemination of preventive measures for patient safety incidents were
implemented as interventions. A pre-post evaluation was conducted to
identify the effect of the new system, and stakeholders’ views on
potential for nationwide implementation.
Results: Eight near-misses were reported three months following
implementation, compared to none prior to implementation. Study
participants expressed satisfaction with the new system’s
user-friendliness, clarity, non-punitiveness, voluntary nature, and
confidentiality protection. The system was perceived to be suitable for
national implementation following refinements.
Conclusions: This evidence-based near-miss reporting system, combined
with the complementary activities implemented in the pilot setting,
should now be introduced into additional hospitals before national
implementation to further enhance its design, support from stakeholders,
and quality and safety impact.