Three near misses occur in two months in which two patients with similar names are almost taken to ENT theatre under the wrong consent form. Each is caught at the team brief; no patient is harmed. What is the best governance response?
Recurrent near misses are valuable safety signals. PSIRF-style learning examines interacting task, technology, environment and organisational factors and closes the loop by testing corrective controls.
A. Remind the last individual involved to be more careful: Individual vigilance alone does not address the repeated system pattern.
B. Take no action because the safety checks worked: Checks mitigated harm, but recurrence signals vulnerable upstream processes.
C. Discipline every staff member involved before gathering facts: A blame-first response suppresses reporting and obscures contributory conditions.
D. Report and aggregate the events, map the work system with frontline staff, introduce targeted identity/consent controls, and measure whether risk falls: A proportionate systems-based response learns across incidents, designs stronger controls and verifies improvement.
E. Add another generic policy without observing the pathway: Policy proliferation is a weak intervention unless it addresses demonstrated work-as-done failures.
If one event had reached the patient and caused harm or distress, immediate clinical remediation and candour would occur alongside the systems response.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, or a substitute for local policy and specialist clinical judgement.
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