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Nonpunitive culture led to hundreds of near-miss reports

Quality Improvement Monitor, September 14, 2007

Near-miss reporting can target potential mistakes before they become sentinel events, but organizations need to do four things before instituting such a program, according to one quality improvement expert:

1. They have to admit that they have a problem

2. They need to acknowledge that incidents are underreported

3. They have to truly want to deal with the problem and report safety issues to the board of trustees

4. Leadership has to pronounce the organization a blame-free environment

So says Yosef Dlugacz, PhD, senior vice president and chief of clinical quality, education, and research at the Krasnoff Quality Management Institute, North Shore-Long Island Jewish Health System (NS-LIJHS) in Great Neck, NY.

Dlugacz should know. Six hospitals in his health system reported 864 near misses from July 2006 to July 2007 as part of the organization's Good Catch program.

"This is a huge improvement and very exciting," Dlugacz says.

Access the full story in the September issue of Quality Improvement Report; access is free for subscribers, nonsubscribers can purchase a copy of the story for $10.

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