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Near Misses and Barriers to Error Propagation
Near Misses
» Incident Learning Systems » Safe Infrastructure » Safety Barriers
Local experience (Ottawa)
From 2007-11 the
Ottawa Hospital Cancer
Centre logged 2500
Incident reports with a
ratio of Potential/Minor
to Actual, non-minor of
51
0
10
20
30
40
50
60
70
Treatment
Preparation
Treatment
Prescription
Booking
% Clinical Incidents
2007
2008
2009
2010
2011
0
10
20
30
40
50
60
70
Treatment
Preparation
Treatment
Prescription
Booking
% Clinical Incidents
2007
2008
2009
2010
2011