Near-miss patient safety events may be one key to creating safer care, but many go unreported.
Hospitals have sophisticated dashboards to measure patient safety events, but that data is not complete without the near misses, workarounds and bedside observations that never make it to the reporting pipelines.
“Absence of harm does not equate to the presence of safety,” Amrita Gupte, MD, chief medical officer at Mount Sinai Queens, part of New York City-based Mount Sinai Health System, said during Becker’s 16th Annual Meeting April 13-16 in Chicago. “We see just the tip of the iceberg. There are so many near misses and great catches that don’t get reported — and we lose that opportunity to learn from those incidents.”
The gap extends beyond near misses to actual harm. A 2025 report from HHS’ Office of Inspector General found hospitals failed to capture 49% of harm events among Medicare patients discharged in October 2018. In 46% of those missed events, staff did not consider the incident to be patient harm, but rather a known complication or side effect.
Systematically analyzing near-miss events through a human factors lens can help hospitals identify underlying workflow and system vulnerabilities, and strengthen front-line interventions and safeguards to prevent errors, according to researchers at Los Angeles-based Cedars-Sinai.
The researchers analyzed 288 near misses reported in the system’s critical care units in 2024 and found nursing interventions accounted for the largest share of near-miss prevention, stopping 41% of events, followed by barcode medication scanning at 31%.
“Nurses’ actions included following up on irregular orders, conducting routine medication safety checks and facilitating communication among care teams,” study author Tara Cohen, PhD, a research scientist and associate professor in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai, said in a Feb. 3 news release. “Their clinical judgment, experience and adherence to safety routines were instrumental in identifying potential threats before they reached patients.”
Reporting depends on whether staff feel safe speaking up. Nearly one-third of clinicians say they speak up when witnessing potentially harmful behavior by colleagues — up from 10% in 2005, a survey led by the American Association of Critical-Care Nurses found. In the survey, 40% of respondents said they reported witnessing broken rules, and 47% confronted the offender to express their concerns. Of respondents, 22% reported witnessing mistakes weekly and 53% reported confronting the offender over mistakes. Organizations that encouraged speaking up, reminding, accountability and challenging assumptions were 2.5 times more proactive regarding patient outcomes and care quality.
Atlanta-based Piedmont Healthcare reduced serious safety events by as much as 90% over the past decade even as it grew from five hospitals to 28. The system expanded its error-prevention tools and integrated “Promise Practice” evidence-based checklists in its EHR that was paired with systemwide dashboards, Lean Six Sigma methodology, and an error-prevention model that empowers front-line employees to flag concerns.
Nearly 47% of healthcare workers report low safety culture perceptions, with lower ratings among clinical staff. A culture of safety also has a workforce effect: Seven of the 10 strongest drivers of employee engagement are related to safety culture, and employees with unfavorable perceptions of safety culture are 1.74 times more likely to leave than those with neutral or positive views.
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