Near Misses

Worried pregnant lady in hospital

Adverse Events, Near Misses & Medical Errors

A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxytocin was administered to induce labor. When the obstetrics team rounded on the patient several hours later, AROM (artificial rupture of membranes) was recommended to accelerate labor. The intern reviewed the patient’s chart …

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Acronym RCA - Root Cause Analysis

Root Cause Analysis

How does learning occur from adverse events, near misses, and errors?   One method is through root cause analysis (RCA).  RCA is a systematic process in which adverse events and near misses are investigated. This approach came from high-risk industries such as nuclear power and aviation and was modified for health care as the patient safety …

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