Near misses

Patient safety isn't just about checklists, it is about making clinical teams aware and interested in patient care improvement, thus changing the culture in healthcare, placing patient safety at the very centre of our daily work.

The concept of medical harm has existed since antiquity, as reported by Hippocrates, and defined as iatrogenesis, derived from the Greek for originating from a physician. Investigators in the Harvard Medical Practice Study defined an adverse event as ‘an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both.’ The Institute for Healthcare Improvement uses a similar definition: ‘unintended physical injury resulting from, or contributed to, by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death’.

Patient harm arises due to errors. An error refers to any act of commission (doing something wrong) or omission (failing to do the right thing) that exposes patients to a potential harm. Adverse events refer to harm from medical care rather than an underlying disease, subcategories of adverse events include: