Article
Practical Radiation Oncology

Missing the Near Miss: Recognizing Valuable Learning Opportunities in Radiation Oncology

By: Palak Kundu, Olivia Jung, Luca F. Valle, Amy C. Edmondson, Nzhde Agazaryan, John Hegde, Michael Steinberg and Ann Raldow

Format:Electronic

Abstract

“Near miss” events are valuable low-cost learning opportunities in radiation oncology as they do not result in patient harm and are more pervasive than adverse events that do. Near misses vary depending on the presence of a latent error of behavior or process, and the presence of an enabling condition predisposing the patient to harm. These nuanced distinctions across near miss types can elicit different cognitive biases affecting the recognition of near misses as learning opportunities. We define near miss types in radiation oncology and explore the differential perceptions among radiation oncology staff.

Keywords

Radiation Oncology; Cognitive Biases; Health Care and Treatment; Learning

Citation

Kundu, Palak, Olivia Jung, Luca F. Valle, Amy C. Edmondson, Nzhde Agazaryan, John Hegde, Michael Steinberg, and Ann Raldow. "Missing the Near Miss: Recognizing Valuable Learning Opportunities in Radiation Oncology." Practical Radiation Oncology 11, no. 3 (May 2021): e256–e262.