What Saves a Patient? A Human Factors Approach to Understanding Near Misses in the ICU

The confluence of rapidly changing clinical conditions, cognitive demands, and interdisciplinary collaboration in intensive care units (ICUs) creates conditions where minor lapses in communication, judgment, or coordination can result in preventable patient harm. Because near-miss events within healthcare systems are underreported and under-analyzed, evidence-based interventions to improve system safety are limited. Therefore, this study aims to understand the conditions that enable near misses using a human factors approach, as well as identify the mechanisms that intercept them before they escalate to harm.

This study analyzed near-miss events reported between January 1 and December 31, 2024, from inpatient critical care units at a large academic medical center in southern California. Events were analyzed to identify contributing factors using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). Events were subclassified and evaluated to identify the intervention source that prevented the escalation from near miss to harm.

A total of 288 near-miss events were reported, and 396 contributing factors were identified. Most events involved routine violations (n = 106, 26.77%), challenges with operational processes (n=105, 26.52%), or skill-based errors (n = 79, 19.95%). Nurses (n = 119, 41.32%) and medication scanners (n = 91, 31.60%) were the most frequent sources of successful intervention.

Near-miss events offer actionable insight into safety vulnerabilities and safeguards within ICU workflows. Targeted interventions, such as improving cross-disciplinary coordination, updating operational processes to reflect practical care delivery, standardizing safety checks, and encouraging the use of reporting systems, can foster a culture of shared accountability and continuous quality improvement.