Introduction
The World Health Organization (WHO) defines a near-miss as an error that has the potential to cause an adverse event (patient harm) but fails to do so due to chance or because it is intercepted (1). There is a relationship between adverse events and near-misses because, according to Heinrich’s Law, “for every adverse event, there are 30 minor injuries and 300 near-misses” (2). Near-misses are considered red flags for future adverse events, offering an opportunity to analyse and address causal factors (3).
Most high-income and several middle-income countries have implemented national-level near-miss reporting systems that routinely collect relevant data from hospitals (4). However, recent research identified few countries in the South and Southeast Asian regions with these systems in place (5). Sri Lanka does not have a comprehensive, holistic national-level near-miss reporting system other than for the specific issues of maternal near-misses (managed by the Family Health Bureau (FHB) and near-misses related to blood transfusion (managed by the National Blood Transfusion Services (NBTS) (6). Limited research has been conducted regarding near-misses in Sri Lanka, confined solely to maternal near-misses (7).
This interventional study, supported by the Sri Lankan Ministry of Health, had the following objectives: 1) explore gaps in the current issue-specific near-miss reporting systems; 2) use this information to develop a more comprehensive, holistic, and effective system; and 3) encourage healthcare professionals to report near-misses and take actions to prevent their recurrence in the future. The overarching aim was to strengthen the structures and processes used for reporting near-misses in Sri Lanka and, in doing so, advance the national quality and safety agenda.