Reporting near misses


Dr Bevan is an anaesthetist in the operating theatre of a large teaching hospital in Wales.


In preparing for a routine hernia repair for Mr Morris, he notices a fault with one of the filters used in the breathing system for the administration of anaesthesia.

Dr Bevan knows that if he had not spotted the fault, it would have meant that Mr Morris would not receive all the necessary gases from the machine. His vigilance means that no harm is done to Mr Morris as there is sufficient time to replace the filter before he arrives in the operating theatre.

What the doctor did. 

Dr Bevan talks to the anaesthetic assistant and the stock manager about the problem with the equipment and the 'near miss' incident. 

The stock manager returns the filter to identify the exact cause of the fault and Dr Bevan completes an incident report form, following the Health Board's policy.
At their meeting to review recent incident reports the hospital management team decide that all the remaining filters should be specifically checked by the safety team, in addition to the scheduled routine checking process for the theatre equipment. The checks show that the filters on all the other machines are working properly.

The management team nevertheless decide to tighten the current system by increasing the frequency of checks on the filters. The incident report form is entered into the National Reporting and Learning System (NRLS), where any similar problems with the filters at other hospitals might be identified and a national alert issued, if appropriate.