Kansas collect near-miss information (Rosenthal, 2003). Private-sector reporting systems are much more likely to collect information on near misses.

The committee believes that near-miss reporting and analysis systems should be fostered. Near misses are often precursors of adverse events, and analysis of their root causes can provide important insights into how to prevent adverse events from happening. In addition, near misses involve some planned or unplanned recovery procedures. These responses to system breakdowns are a key element of learning from near misses. Identifying what recovery procedures work in practice helps in developing better care delivery systems. The functional requirements of near-miss analysis systems and the implications for data standards are examined in Chapter 7.


Australian Council for Safety and Quality in Health Care. 2001. Safety in Numbers: A Technical Options Paper for a National Approach to the Use of Data for Safer Health Care (Work in Progress). Online. Available: http://sq.netspeed.com.au/articles/Publications/numbers.pdf [accessed March 4, 2002].

Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press.

National Patient Safety Agency, Department of Health, United Kingdom. 2001. Doing Less Harm (Version 1.0a). Online. Available: http://www.npsa.org.uk/admin/publications/docs/draft.pdf [accessed April 16, 2002].

Rosenthal, J. 2003. State Reporting Systems Collecting Information on Near Misses. Personal communication to Institute of Medicine’s Committee on Data Standards for Patient Safety.

Runciman, W. B., and J. Moller. 2001. Iatrogenic Injury in Australia. Adelaide, Australia: Australian Patient Safety Foundation, Inc.

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