The Research

The researchers devised a spectrum of hypothetical near misses based on real-life practice. Employees were asked to rank the likelihood that they would report the following near-miss scenarios, which become progressively more threatening to the patient:

• Could have happened. The pacemaker status of a patient was not checked at the initial consultation.
• Fortuitous catch. The pacemaker status was not checked.
• Almost happened. The pacemaker status was not checked.