DEVELOPING AND EVALUATING A NATIONAL NEAR-MISS REPORTING SYSTEM FOR SAFER HEALTHCARE IN SRI LANKA
DOI:
https://doi.org/10.17501/26138417.2026.9103Keywords:
near-miss reporting, patient safety, incident reporting systems, health systems, quality improvement, Sri LankaAbstract
Near-miss reporting systems are essential for strengthening patient safety yet remain underdeveloped in many low- and middle-income countries. This pilot study assessed the feasibility of implementing a structured near-miss reporting system in a public hospital in Sri Lanka and examined its effects on staff knowledge, perceptions, and reporting behaviour. A pre–post intervention study was conducted at a district general hospital. The interventions included development of a reporting form and guidelines, expert consultation, staff training, distribution of reporting materials, and establishment of a reporting box with periodic reminders. Knowledge, perceptions, and self-reported behaviour were assessed before and after implementation using a validated questionnaire. Reported near-misses during the intervention period were categorized and analyzed descriptively. Knowledge and perception scores improved among both medical and nursing officers following implementation, with larger gains among those who attended the training programme. Reporting behaviour showed only moderate improvement, and eight near-misses were reported during the three-month intervention period, most of which were related to radiology, laboratory processes, and patient monitoring. This pilot demonstrates that a structured near-miss reporting system can be introduced successfully in a resource-constrained public hospital, improving foundational knowledge and perceptions. However, reporting behaviour remained limited, underscoring the need for stronger feedback mechanisms, continuous case-based learning, and a supportive organizational culture. These findings provide an important foundation for national scale-up and further refinement of near-miss reporting within the Sri Lankan health system.
Downloads
References
Auciello, S. E. (2016). Re: Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine, 29(1), 165. https://www.jabfm.org/content/29/1/165
Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., et al. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine, 28(4), 452–460. https://www.jabfm.org/content/28/4/452
Crane, S., Sloane, P. D., Elder, N. C., Cohen, L. W., Laughtenschlager, N., & Zimmerman, S. (2017). Implementing near-miss reporting and improvement tracking in primary care practices: Lessons learned. In Advances in patient safety and medical liability. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK493156/
Dyab, E. A., Elkalmi, R. M., Bux, S. H., & Jamshed, S. Q. (2018). Exploration of nurses’ knowledge, attitudes, and perceived barriers towards medication error reporting in a tertiary health care facility: A qualitative approach. Pharmacy (Basel), 6(4), 127. https://www.mdpi.com/2226- 4787/6/4/127
Elkhider, S., & Savage, B. M. (2020). Missing chances to learn: A case study of barriers to near-miss reporting in a hospital. Business Process Management Journal, 26(3), 721–735. https://doi.org/10.1108/BPMJ-03-2019-0110
Etchegaray, J. M., Thomas, E. J., Geraci, J. M., Simmons, D., & Martin, S. K. (2016). Differentiating close calls from errors: A multidisciplinary perspective. Journal of Patient Safety, 1(3), 133– 137. https://doi.org/10.1097/01.jps.0000176773.45451.24
Evans, S. M., Smith, B. J., Esterman, A., Runciman, W. B., Maddern, G., Stead, K., Selim, P., O’Shaughnessy, J., Muecke, S., & Jones, S. (2007). Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Quality and Safety in Health Care, 16(3), 169–175. https://doi.org/10.1136/qshc.2006.019349
Fujita, S., Seto, K., Hatakeyama, Y., Onishi, R., Matsumoto, K., Nagai, Y., et al. (2021). Patient safety management systems and activities related to promoting voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues: A cross-sectional study. PLoS ONE, 16(7), e0255329. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255329
Jayaratnam, S., Franklin, R., & de Costa, C. (2022). A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to? Australian and New Zealand Journal of Obstetrics and Gynaecology, 62(2), 198– 213. https://researchonline.jcu.edu.au/72584/
Jayathilake, A., Karthikeyan, P., & Arnold, S. (2022). Knowledge and practices of medical officers on medical near misses in a tertiary care hospital, Sri Lanka. International Journal of Multidisciplinary Research and Analysis, 5(2), 414–419.
Kodate, N., Taneda, K., Yumoto, A., & Kawakami, N. (2022). How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study. BMC Health Services Research, 22(1), 241. https://doi.org/10.1186/s12913-022-07631-0
Kostopoulou, O., & Delaney, B. (2007). Confidential reporting of patient safety events in primary care: Results from a multilevel classification of cognitive and system factors. Quality & Safety in Health Care, 16(2), 95–100. https://qualitysafety.bmj.com/content/16/2/95
Ministry of Healthcare and Indigenous Medicine. (2020). Facilities offered at different categories of medical care institutions – 2020. In Amendments to the general circular No. 02-61/2005. Ministry of Healthcare and Indigenous Medicine.
Mitchell, I., Schuster, A., Smith, K., Pronovost, P., & Wu, A. (2016). Patient safety incident reporting: A qualitative study of thoughts and perceptions of experts 15 years after “To Err is Human”. BMJ Quality & Safety, 25(2), 92–99. https://qualitysafety.bmj.com/content/25/2/92 (qualitysafety.bmj.com in Bing)
Park, M. H., Kim, H. J., Lee, B. W., Bae, S. H., & Lee, J. Y. (2016). Near misses experienced at a university hospital in Korea. Quality Improvement in Health Care, 22(1), 41–57. https://www.qihjournal.org/journal/view.php?doi=10.14371/QIH.2016.22.1.41
Pham, J. C., Girard, T., & Pronovost, P. J. (2013). What to do with healthcare incident reporting systems. Journal of Public Health Research, 2(3), e27.
https://doi.org/10.4081/jphr.2013.e27 (doi.org in Bing)
Reed, S., Arnal, D., Frank, O., Gomez-Arnau, J. I., Hansen, J., Lester, O., et al. (2014). National critical incident reporting systems relevant to anaesthesia: A European survey. British Journal of Anaesthesia, 112(3), 546–555. https://doi.org/10.1093/bja/aet387
Samaranayaka, G. D. (2023). Knowledge, attitudes, and practices of hemovigilance among doctors in a Sri Lankan tertiary care center. Asian Journal of Transfusion Science, 17(1). Advance online publication. https://doi.org/10.4103/ajts.ajts_59_22
Sample Size Calculator by Raosoft, Inc. (n.d.). http://www.raosoft.com/samplesize.html
Singal, M., Zafar, A., Tbakhi, B., Jadhav, N., Alweis, R., & Bhavsar, H. (2018). Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system. Journal of Community Hospital Internal Medicine Perspectives, 8(5), 253–259. https://doi.org/10.1080/20009666.2018.1527670
Smith, K. S., Harris, K. M., Potters, L., Sharma, R., Mutic, S., Gay, H. A., Wright, J., Samuels, M., Ye, X., Ford, E., & Terezakis, S. (2014). Physician attitudes and practices related to voluntary error and near-miss reporting. Journal of Oncology Practice, 10(5), e350–e357. https://doi.org/10.1200/JOP.2013.001353
Tanaka, K., Otsubo, T., Tanaka, M., Kaku, A., Nishinoue, N., & Takanao, T. (2010). Similarity in predictors between near miss and adverse event among Japanese nurses working at teaching
hospitals. Industrial Health, 48(6), https://www.jstage.jst.go.jp/article/indhealth/48/6/48_MS1151/_article
World Health Organization. (2005). Draft guidelines for adverse event reporting and learning systems. World Health Organization. https://www.who.int/publications/i/item/WHO-EIP-SPO-QPS- 05.3
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Dr M P Jayalath, Dr PVDS Dharmagunawardene, Prof Samath D Dharmaratne, Prof Reece Hinchcliff
This work is licensed under a Creative Commons Attribution 4.0 International License.
