Dokuz Eylul University Hospital Anesthesia Intensive Care Unit's ri̇sk management, specification of near-miss events

Objective: Providing the main principles in health quality improvement and accreditation, which include effective, efficient, fair, safe, patient, patient relative-employee oriented health services at the promised time, is directly related to specifying near-miss events, analyzing their reasons, and preventing them. In this study, it was aimed to specify and evaluate the near-miss events that may affect the health and safety of the employees and patients in Dokuz Eylul University Hospital Anesthesia Intensive Care Unit, and to perform a risk analysis in order to control these risks, and to take corrective actions in this unit according to the results of this analysis. Method: In order for Dokuz Eylul University Hospital Anesthesia Intensive Care Unit employees to meet on common ground, meetings were held at a time when there would not be any obstacle for the workflow within the unit for awareness training on risk, risk analysis, and near-miss events. At the first meeting, awareness was raised about the concepts mentioned above. At the second meeting, near-miss events were specified by reinforcing awareness and examining the workflows. At the third meeting, near-miss events were specified by examining the workflows. At the fourth meeting, root cause analysis was performed on the specified near-miss events by fishbone method (cause-and-effect diagram). At the last meeting, by using Dokuz Eylül University Risk Management Directive, risk levels were specified by making the risk analysis about the effects of near-miss events on the workflow and by making classification according to the impact-probability scores. Results: Intensive care unit personnel's and patients' cases of exposure to different risks were specified at the end of the meetings and analyses performed. With the trainings given in those meetings, the unit personnel were informed about the near-miss event, risk analysis studies and risk management. 19 near-miss events were specified by the unit personnel. At the end of the risk analysis study, the "risk level" of 1 of them was specified as very low level risk, 4 of them as low level risk, 13 of them as medium level risk and 1 of them as high risk level. Conclusion: For assuring patient and employee safety, it is necessary to specify near-miss events, analyze their reasons, evaluate the results, and in this regard, develop and monitor corrective actions within the institution in order to provide main principles in health quality, which include effective, efficient, fair, safe, patient-patient relative-employee oriented health services at the promised time. Key Words: Near Miss Event, Risk Analysis, Risk Management