What's in a Name........?

Categorizing Errors and Adverse Events for Learning: A Provider Perspective. Ginsburg L et al. Healthcare Quarterly 2009; 12: 154 - 160

'Near miss,' 'medical error,' adverse event,' 'harm,' 'preventable adverse event,' 'variance,' 'sentinel event' - a bewildering number of terms like these is used in patient safety to indicate different types of events. (An umbrella term for all these is 'patient safety events.') Often there is confusion among health professionals about what to call an event or an incident and much misunderstanding may result from this. 

To understand what front-line providers and managers thought about such terms, and to identify which types of events they thought were most suitable for learning in order to improve patient safety, the authors of this paper conducted focus groups with patient safety officers, patient care managers, nurses and other allied health professionals. 

The authors presented the following categorization of events to the participants: (1) near misses, (2) preventable adverse events causing minimal harm but no prolonged hospitalization, (3) preventable adverse events that resulted in prolonged hospitalization but no permanent harm to the patient and (4) sentinel events (events that resulted in permanent disability or death).  The focus group participants:

1. preferred a simple classification of events into 'major events' and 'minor events,' with a further sub-classification of the events by the degree of harm that was actually observed or could have occurred. They did not like the above categorization - it was not intuitive, was too fine-grained, and too restrictive. 
2. believed that preventable events should be the focus of learning opportunities, as opposed to non-preventable events (such as an allergic reaction to a medication that occurs for the first time).
3. thought that near-misses were an important way of learning how to improve patient safety.
4. disagreed on which type of events were more valuable for leaning - events actually causing severe harm, or those that could have caused severe harm (but did not). 

Other findings from the focus groups were:

• Attribution of harm to an event is sometimes difficult. For example, it may be difficult to determine whether an event truly caused prolonged hospitalization or whether the disability it caused is permanent.
• Preventability might be hard to determine in certain cases. 
• The word 'preventable' is bothersome because it implies that the health professional is at fault, and not other aspects of the system.
• Near-misses are often unreported or unnoticed, and are complex to identify and categorize.
• Near-misses should be categorized based on the severity of the harm that could have resulted, and how close to the patient they were caught.
• When an even causes serious patient harm, it can lead to significant and long-lasting learning, but can be hard to discuss. In contrast, near-misses that could have potentially caused harm are easier to discuss, but may not be taken as seriously as actual catastrophic events.

Based these results, the authors developed and refined a new typology of patient safety events, to be used for all patient safety events except those that are clearly non-preventable: 

Minor Event: An event involving no harm or very minimal temporary harm to the patient 

Moderate Event: An event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention, but poses no significant or permanent risk of harm to the patient. 

Major Event: An event involving death or serious physical/ psychological injury.  

Minor Near-miss: An event that would have resulted in no harm or very minimal temporary harm to the patient but did not because it was caught or because of good luck. 

Major Near-miss: An event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck.