Alexis Roam, RN-BCOn a crisp day in December, a lady is clearing overgrown brush and small trees with a lightweight chainsaw on her family farm. As the minutes turn to hours, she begins to flag. The saw eventually feels cumbersome but powerful, capable of taking down the mightiest trees.

She notices a limb dangling at a precarious angle from a dying oak and decides it will be the last cut before a lunch break. With arms straining from fatigue, she hefts the saw up, but the chain catches on her pants. Time seems to stop as she wonders what she’ll see when she looks down at her leg.

A Second Scenario

In the same moment, a patient with medical complexities is admitted to a skilled nursing facility (SNF) for post-acute skilled services. She hopes to be home for Christmas to celebrate with family.

While the patient settles in, the charge nurse reads the hospital transfer orders, including the medication orders in the packet left on her desk 20 minutes ago. She looks up and notices she’s late obtaining blood sugar results and administering insulin.

Over the next two hours, the nurse intermittently enters the hospital transfer orders in the electronic health record (EHR) while completing dressing changes; hanging a new bag of IV fluids; and answering phone calls from two family members, the lab, a physician’s office, and a dialysis clinic irate that their patient is being picked up late.

She also completes the new patient’s admission nursing assessment and finally enters the last of the hospital transfer orders into the EHR for the physician to approve. She clocks out feeling exhausted and ready for a few days off. The nurse is unaware that she entered two medication errors into the EHR.

Over the next three days, the patient’s condition deteriorates, and she begins to lose hope she’ll be home for Christmas. Soon after, she finds herself on a gurney in the emergency room, with an oxygen mask covering her face, wondering if she’ll ever make it home.

Near Misses?

Are the case examples a near miss or an adverse event? An estimated 33 percent of Medicare beneficiaries experience an adverse event after being discharged from a hospital stay and admitted to a SNF, according to a report by the Office of Inspector General (OIG) in February 2014, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.” 

What’s startling is an estimated 59 percent of those adverse events could have been prevented, OIG said.
These findings spurred a call for action, with the Centers for Medicare & Medicaid Services leading a national campaign and partnering with stakeholders to support the development of education and resources, all made available to SNFs. Regulations have also introduced requirements specifically addressing the prevention of adverse events.

For example, F866 in Appendix PP of the State Operation Manual says one of the facility policies and procedures for QAPI (Quality Assurance and Performance Improvement) must include “facility adverse event monitoring, including the methods the facility will systematically identify, report, track, investigate, analyze, and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.” The message is clear: Providers must prioritize adverse event prevention.

Consider the predicaments of the two characters in the examples. The lady on her family farm looks down and is relieved to see her pants are torn, but her leg escaped being mangled. The patient who had to return to the hospital is readmitted to the SNF and in two weeks is discharged home before Christmas. The medication errors were unrelated to her deterioration and hospital stay.

Adverse Events Waiting to Happen

These are cases of near misses, which often precede adverse events. The Agency for Healthcare Research and Quality defines a near miss as “any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome.” Using this definition, it’s clear that good fortune, rather than sound process, prevented the adverse event. 

What should happen next in the near miss cases? Does the lady wielding the saw continue working and risk cutting her leg? Or does she stop and investigate the near miss using what she learned to change the way she works with the saw? The answer is obviously to investigate and make a change to decrease the risk of injury.

Applying this question to the patient’s case, it’s easy to identify what should have been done, but much more complex to operationalize processes that capture and investigate the near miss. Ignoring the near miss leaves leadership unaware of multiple risks and warning signs of patient harm, as well as insight into the burnout nurses experience, contributing to turnover.

Stating the Facts

Consider the following problems that could lead to an adverse event in the patient case example.
The nurse lacked critical information about the patient prior to admission. There was no opportunity to ask questions or receive guidance. 

There was no medication reconciliation process, which is part of the overall drug regimen review. If the nurse was expected to reconcile the medications, the time wasn’t allocated to do so.

There was no drug regimen review (DRR) initiated. The nurse did not have the information, time, and perhaps competency to do this.

Facilities should consider the competency of nurses involved with DRR, as not all nurses have this skill set. Education, higher-level clinical assessment experience, and pharmaceutical expertise are some of the areas to consider in competency evaluation.

Also, the pharmacist is the expert regarding drug therapy actions and interactions, often providing critical information for nurses and physicians. While the SNF Quality Reporting Program DRR measure does not require the involvement of the pharmacist, the pharmacist can collaborate and enhance patient safety to avoid adverse events related to drug therapy. 

Responsibilities and roles weren’t aligned with processes that will produce consistent quality outcomes. The time the nurse spent on some of the phone calls would have been better utilized caring for patients.
In this case, the charge nurse was not the optimal choice to be responsible for safely conducting the admission medication reviews. There were too many interruptions and tasks and a problematic lack of collaboration with other clinicians.

Information-Gathering Critical

In the case example, the patient was fortunate the gaps—a lack of processes and competent clinicians with appropriate responsibilities assigned to them—did not cause an adverse event. But the next patient may not be so lucky. To begin to heed warnings, leadership must value the information gleaned from the near miss just as much as they value the information from adverse events. This will enhance the patient safety culture and empower next steps. 

Just as with error reporting, employees must understand blame and disciplinary action is not the objective. Rather, the objective is to collect valuable insight into the warnings that often precede an adverse event. Align policies and actions to support near miss reporting, as well as error reporting. 

Design near miss reporting to be easy to do and clearly understood.

Educate staff not only on how, but also why to report the near miss. Consider explaining the near miss as a close call situation, and when in doubt, report.

Tell staff how catching the near miss has helped residents. This feedback reinforces the importance of reporting and demonstrates leadership does indeed use the information to enhance patient safety, according to the National Safety Council’s “Near Miss Reporting Systems.”
Alexis Roam, RN-BC, MSN, DNS-CT, QCP, is curriculum development specialist with the American Association of Post-Acute Care Nursing. She can be reached at