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What near misses tell us about risk and safety in mental health care


  • Funding: Funding was provided for this study by the Canadian Patient Safety Institute Research Competition 2008.

L. Jeffs, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 5-060 Bond Wing, 30 Bond Street, Toronto, ON, Canada M5B 1W8, E-mail:


Accessible summary

  • • How near misses in the mental health sector are experienced is not well understood.
  • • Study findings elucidate the nature of near misses as both (1) vulnerabilities and risk associated with the mental health population (e.g. violence, aggression, fear and error proneness); and (2) ‘no-harm events’ where clinicians or service users minimize or prevent harm from happening.
  • • Study findings have implications for practice, education, research and policy associated with recognizing and responding to safety threats in a timely manner to prevent harm to service users and providers.


How service providers and service users view near misses in their daily practice within the rubric of patient safety events is not well understood. Further no studies were located that explored near misses specifically in mental health settings in Canada. In this context, a qualitative study was undertaken to gain insight into how service providers and service users (mental health clients or their family members) experienced and defined near misses. Eight (8) focus groups (n= 88) with service providers and 28 semi-structured interviews with service users were conducted at three mental health care organizations. Content analysis was employed to the dataset that elucidated that near misses were (1) safety threats and vulnerabilities associated with experiencing mental illness; and (2) acts that avert harm and prevent something from happening. Findings are compared to what is currently known about in safety. Implications of findings for practice, research and policy are delineated.