FIGURE 7-1 Incident causation model.

SOURCE: Van der Schaaf, 1992.

nesses in the health care system (errors and failures, as well as inadequate system defenses) and (2) that on the strengths of the health care system (unplanned, informal recovery actions) which compensate for those weaknesses on a daily basis, often making the essential difference between harm and no harm to a patient. Informal recovery actions are similar to the characteristic strengths of a highly reliable organization or a culture of safety, as identified by Roberts (2002).

Health care is an example of a low-reliability system, where frquently all that stands between an adverse event and quality health care is the health care provider. Health care professionals are continually detecting, arresting, and deflecting potential adverse events, sometimes even subconsciously. Data on recovery processes represent valuable patient safety information, a fact that often goes unrecognized.

The remainder of this chapter makes the case for the importance of near-miss reporting and analysis. The next two sections outline, respectively,



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