Quality Improvement Tracks ‘Near Misses’ for Review

Overview:

All near misses are written in a red book, and once a month there is an anesthesia meeting where the group discuss them. They talk about the literature and how their practices can change to avoid these situations in the future.

We actually have a fairly well established mortality and morbidity process here. We have the red book, which I can show you because we always write our near misses in there and every month, at the anesthesia meetings, we sit around as a group and discuss them and what the literature says about this, [and] how can we change our practices. We actually do a fairly good quality improvement practice.