Learning from Near Misses and Low-Level Disruptions

Serious incidents are rarely isolated events. Near misses and low-level disruptions often provide early warning signs that are critical to risk prevention.

This article supports learning from incidents and disruptions and links with incident management and escalation.

The value of near-miss reporting

Near misses highlight system vulnerabilities without resulting in harm, offering valuable learning opportunities.

Operational example: Medication near misses

Repeated near misses identified unclear labelling and storage issues, prompting environmental and procedural changes.

Operational example: Staffing cover gaps

Low-level staffing disruptions revealed weaknesses in on-call arrangements, addressed before serious impact occurred.

Operational example: Environmental risks

Minor slips and trips highlighted environmental hazards that were resolved before injuries occurred.

Commissioner expectations

Commissioners expect providers to encourage reporting of near misses without blame and to demonstrate learning.

Regulatory expectations

Inspectors assess whether providers value early warning signs or focus only on serious incidents.

Creating a learning culture

Staff confidence to report near misses is essential for effective learning and prevention.

Assurance and review

Providers track near-miss themes and test whether learning reduces future risk.

Preventing escalation

Systematic learning from low-level disruptions reduces the likelihood of serious incidents.