almost miss , " close click ", " close call ", or " almost collision " are events that are not planned that could potentially cause, but not actually result in human injury, environmental damage or equipment, or disruption to normal operation.
OSHA defines almost as an incident where no property is damaged and no personal injury is sustained, but where, given the slight shift in time or position, damage or injury can easily occur. Near misses can also be referred to as close calls, near accidents, accident accidents, injury-free events and, in the case of moving objects, near collisions.
Losing distance is often a mistake, with danger prevented by consideration and other circumstances.
The phrase "near miss" can not be confused with the phrase "almost missed" which would imply a collision.
Video Near miss (safety)
Cause
There are factors for almost operator-related, and context-related factors. Fatigue is an example for the former. The risk of car accidents after more than 24 hours of shift for doctors has been observed increased by 168%, and the risk of near loss by 460%. Context-related factors include time pressures, foreign arrangements, and in the case of health care, diverse patients, and increased staff-to-nurse ratios increase.
Maps Near miss (safety)
Reporting, analysis and prevention
Most safety activities are reactive and not proactive. Many organizations await losses occur before taking steps to prevent a recurrence. The incidents of near accidents often precede the event of loss of production but are largely ignored because no (no injury, damage or loss) occurs. Employees are not enlightened to report these close calls because there is no interruption or loss in the form of injury or property damage. Thus, many opportunities to prevent accidents that have not disappeared from the organization. Recognizing and reporting near-miss events can make a big difference to worker safety within the organization. History has shown repeatedly that most of the events of the losses (accidents) are preceded by a warning or near accidents, sometimes also called short-distance calls, narrow escapees or close attacks.
In terms of human life and property damage, there is hardly a cheaper, zero-cost learning opportunity (compared to learning from actual injury or property loss events)
Getting a very high amount is the goal as long as the numbers are within the organization's ability to respond and investigate - otherwise it is a paper work exercise and a waste of time; it is possible to achieve a ratio of 100 near misses reported per incident of loss.
Achieving and investigating the high ratio of melee errors will find the underlying cause and root cause of potential future accidents, resulting in a 95% reduction in actual losses.
An ideal miss event reporting system includes liabilities (for incidents with high potential losses) and voluntary reporting and not penalizing witnesses. The key to almost nonexistent reports is "the lessons learned". Close to the journalists can explain what they observe from the beginning of the event, and the factors that prevent the occurrence of losses.
The near-miss events cause the targeted root cause analysis to identify defects in the system that result in errors and factors that can strengthen or improve outcomes.
In order not to happen again, organizations must institutionalize teamwork training, feedback on performance and commitment to advanced data collection and analysis, a process called sustainable improvement.
Near misses are smaller in scale, relatively easier to analyze and easier to complete. So, catching almost does not only provide inexpensive ways of learning, but also has some profitable spin offs:
- Capture enough data for statistical analysis; Trend studies.
- Provides great opportunities for "employee participation," the basic requirements for successful occupational health and safety programs. It embodies principles of behavioral shifting, responsibility sharing, awareness, and incentives.
- One of the main problems in the workplace that almost fails in reporting incidents that try to solve directly or indirectly is trying to create an open culture where everyone shares and contributes responsibly. Near-Miss reporting has been shown to improve employee relations and encourage teamwork in creating safer work environments.
Increased safety according to report
Close reporting by observers is a well-established error-reduction technique in many industries and organizations:
Flights
In the United States, the Aviation Safety Reporting System (ASRS) has collected secret confidential reports from close calls from pilots, flight attendants, air traffic controllers since 1976. The system was established after TWA Flight 514 crashed as it approached Dulles International Airport near Washington, DC, killing all 85 passengers and seven crewmen in 1974. A later investigation found that the pilot misunderstood the ambiguous response of Dulles air traffic controllers, and that earlier other airlines had told the pilot, but not with other airlines, about similar near miss. ASRS identifies flaws and provides data for improvement planning to stakeholders without regulatory action. Some familiar security rules, such as turning off electronic devices that may interfere with navigation equipment, are the result of this program. Due to near miss observations and other technological improvements, the fatal accident rate has dropped by about 65 percent, into one fatal accident around 4.5 million times of departure, from one in nearly 2 million in 1997.
In the UK, the report near miss flights is known as "airprox", the danger of air closeness, by the Civil Aviation Authority. Since the reporting started, the plane near the misses continues to decline.
Fire-saving services
The death rate and injury of firefighters in the United States has not changed for the past 15 years despite an increase in self-protective equipment, apparatus and reduction in structural fires. In 2005, the Near National Firearms Reporting System was established, funded by grants from the US Fire Department and Fireman Dana Asuransi, and authorized by the International Association of Fire and Fighting Chiefs of the International Association. Each member of the firefighting service community is encouraged to submit a report when he or she is involved, witnesses, or informed about a near missed event. Reports may be anonymous, and not forwarded to any regulatory agency.
Law enforcement and public security
A total of 1,439 US law enforcement officers died in duty over the last 10 years, averaging one death every 61 hours or 144 per year. There are 123 law enforcement officers killed in duty by 2015. In 2014, the Law Enforcement Officer (LEO) near the Miss Reporting System was established, with funding support from the US Department of Justice's Office for Environmental Policing Services (COPS Office). Since its launch, the LEO Near Miss system has established support and partnerships with the National Memorial Enforcement Officers' Memorial Fund (NLEOMF), the International Association of Chiefs of Police (IACP), the International Association of Standards and Training on Law Enforcement (IADLEST), Officer Down Memorial Page (ODMP ) and organizations under 100. The Police Foundation, a national independent nonprofit organization, operates the system and has received additional support from the Motorola Solutions Foundation. Law enforcement members must submit voluntary reports when engaged or witness or become aware of near miss events. The near miss report takes several minutes to send, can be anonymously submitted and not forwarded to regulatory or investigative agencies, but is used to provide analysis, policy recommendations and training to law enforcement communities.
Health Care
AORN, a registered professional organization of US registered peri- liver nurses, has implemented a voluntary close-up reporting system called SafetyNet covering transfusion treatment or reactions, communication or consent issues, patients or faulty procedures, communication disorders or tech malfunctions. The incident analysis allows security notices to be issued to AORN members.
The United States Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) developed the Patient Safety Reporting System that is modeled on the Aviation Safety Reporting System to monitor patient safety through voluntary, confidential reports.
The Near Miss Registry is an anonymous, risk-free reporting tool, almost non-existent in Internal Medicine, sponsored by the New York State Department of Health and administered by the New York Chapter of the American College of Physicians. This tool collects information about both near medical errors and the obstacles that make these mistakes reach the patient.
AlmostME is a commercial solution for near-miss reporting in health, education, public services, aviation and manufacturing.
Rel
CIRAS (Secret Incident Reporting and Analysis System) is a confidential reporting system modeled on ASRS and was originally developed by Strathclyde University for use in the Scottish railway industry. However, after the Ladbroke Grove rail accident, John Prescott mandated its use throughout the railroad industry in the UK. Since 2006, CIRAS is run by an autonomous Charity trust.
See also
- Air security
- Confidential incident reporting
- Error
- Hazard analysis
- Miss the mother
- Patient safety
- Road traffic security
- The root cause
- Analysis of root causes
- Security techniques
- Separation (air traffic control)
References
External links
- Reviews of Colombian Journalism: 'Almost Miss'
Source of the article : Wikipedia
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