Building a Near-Miss Culture: The 90 Percent You'll Never See in Your Dashboard


 Building a Near-Miss Culture: The 90 Percent You'll Never See in Your Dashboard

Everybody says “near misses are important,” but let me tell you what actually happens in a hospital. A tech catches a missing indicator, fixes it on the spot, and keeps it moving. An endo nurse notices a wrong connector, swaps it out, and starts the case. A scheduler spots a conflict and quietly reroutes the patient. None of that ever becomes “data.” It’s just people preventing harm in real time. If quality only shows up when there’s an incident report, we are missing 90 percent of what keeps patients safe. Here’s what I care about as a quality leader: 

– Can people fix something small without getting in trouble? 
– Do we make it easy to log a 30‑second note when something almost went wrong?

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