A study of 288 critical care incidents found barcode scanning technology and nurse intervention frequently stopped potential patient harm before it occurred.
A new study published in The Joint Commission Journal on Quality and Patient Safety found that nurses’ clinical interventions—often supported by technologies such as barcode medication scanners—play a major role in preventing patient harm from near-miss events in intensive care units.
Researchers at Cedars-Sinai in Los Angeles analyzed 288 near misses reported in 2024 from inpatient critical care units within the health system. Near misses are events that could potentially cause harm but do not reach the patient.
“Nurses’ actions included following up on irregular orders, conducting routine medication safety checks, and facilitating communication among care teams,” says Tara Cohen, PhD, corresponding author of the study and a research scientist and associate professor in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai, in a release. “Their clinical judgment, experience, and adherence to safety routines were instrumental in identifying potential threats before they reached patients.”
Interventions Preventing ICU Harm
Using a human factors approach, investigators identified 396 contributing factors across the events and examined the interventions that prevented them from escalating into harm.
Nurses were the most frequent source of intervention, accounting for 41% of near misses. Barcode medication scanners contributed to 31% of interventions, while equipment or machines accounted for about 1%. The source of intervention could not be identified in 15% of cases.
“Patient safety is of the utmost importance to our team,” says Cristina R. Ferrone, MD, chair of the Department of Surgery at Cedars-Sinai, in a release. “It’s important that we continue to evaluate these ‘near-miss’ situations to determine how to prevent potentially harmful events in the future and continue to provide exceptional patient care.”
Elizabeth Mort, MD, MPH, vice president and chief medical officer of Joint Commission and editor-in-chief of the journal, said the findings highlight the combined role of staff and technology in improving safety.
“Joint Commission commends Cedars-Sinai for exploring how to make patient care safer—and for sharing these learnings from near-miss events with the healthcare community,” Mort says in a release. “Nursing stands at the heart of patient care, and their presence at the bedside and adoption of technology is integral to quality and safety.”
Mort adds, “By understanding how staff and technology are integral to patient safety, healthcare leaders can innovate to strengthen our systems and support their teams in preventing future adverse events.”
Peter L. Slavin, MD, president and CEO of Cedars-Sinai, says the research highlights the importance of empowering frontline clinicians to identify risks before harm occurs.
“Our research underscores the value of empowering healthcare professionals, particularly nurses, to identify opportunities that can prevent harm from reaching patients,” Slavin says in a release. “The findings also point to the important role of technology, such as barcode scanning, in addressing safety gaps. We are proud to see our research contribute to the safety of patients at Cedars-Sinai and beyond.”
ID 132942616 © Sudok1 | Dreamstime.com
