Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. A study published in Journal of Surgical Research sought to evaluate directly observed variances that occur in the pediatric operating room and to correlate these with the two established variance reporting systems in that hospital. Despite multiple reporting systems, near misses and adverse events remain underreported. Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. The study concludes that identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.
- Are we missing the near misses in the OR?—underreporting of safety incidents in pediatric surgery. Journal of Surgical Research. January 2018.