In 1998, around this time of year, when the spring snow was wet and heavy, I was skiing helmetless with my 7-year-old son at Mt. Mansfield in Stowe. Austrian skier Hermann Maier had recently won the Winter Olympic Super G race with a spectacular performance in Nagano. Visions of his finish entered my imagination as I tucked around the base of the Perry Merrill trail; the roaring of crowds filled my ears as I flew toward the intersection with Nosedive and my finish line.
From out of nowhere, another skier appeared who also seemed to be racing for the gold in the opposite direction. A split-second later, this large man and I crashed head-on, projecting my body into the woods. I regained consciousness only to find my frightened young son and several ski patrol medics peering anxiously into my eyes as they strapped me onto a backboard.
In over two decades of skiing, I had fallen many times and, prior to this accident, just shook my head and laughed as I reassembled my scattered equipment and dignity. I had never considered the possibility of getting seriously hurt. This time, I was lucky to escape with three fractured ribs, loose front teeth and a concussion. Lesson learned: The following winter, I donned a helmet for the first time.
Why had I previously responded to my skiing falls with laughter rather than concern? Studies in psychology show I am not alone in my denial. Recognizing and learning from near misses is not what people usually do. Most close calls are ignored or misread rather than studied as opportunities for improvement. In fact, close calls followed by a successful outcome, even when luck played an obvious role in averting disaster, lead those involved to view the near miss as a sign that the system is resilient and functioning well.
In recent years, the value of near misses as free lessons in error prevention has been recognized in many industries, including telecommunications, automobile production, NASA projects, pharmacology manufacturing and aviation.
Strategies that have been implemented in these fields as a result of near-misses include: being increasingly alert when time or cost pressures are high, watching for deviations from the norm and uncovering root causes, asking decision-makers to be accountable for near misses, envisioning worst-case scenarios, watching for near misses masquerading as successes, and rewarding individuals for exposing near misses.
Near misses also occur in hospitals, where they are invaluable opportunities to learn how to prevent more serious errors that could lead to catastrophic complications or death. But identifying these events in medical care is difficult.
The user group in healthcare — the patient — is in a uniquely vulnerable position where it can be difficult to distinguish near misses from proper protocol. I have often talked with patients or family members who recognized events during a hospitalization that they questioned or found worrisome. Examples include unfamiliar pills found in a medication cup, salt packets delivered on the food tray of a loved one with heart failure, an IV in an arm swollen from previous surgery, unlabeled urine samples left in an unprotected place, prescriptions for medication the patient is allergic to, or healthcare workers simply not washing their hands.
Most of the time, the patient or visitor does not voice these concerns for fear of seeming challenging, disrespectful, or because of assumptions that everything is OK. For a patient or family member already worried and uncertain, speaking up can feel intimidating rather than empowering.
If the clinical staff, however, invited feedback, these proactive observers would become highly motivated resources. By watching for events that might precede a crisis, this patient advocate group could become an invaluable part of quality control in healthcare and help prevent harmful errors.
Lesson learned: If you see an action that seems out of place, speak up. Do not assume doctors and nurses are always correct. Create your own checklist of things to watch for. Tell the clinical staff about your intention to ask questions.