Incident Reporting and Learning from Near Misses

Patient safety is a shared responsibility across the healthcare team. Healthcare professionals often work within complex systems where high workloads, time pressures, communication challenges, and human factors can increase the risk of incidents. Incident reporting, including the reporting of near misses, is a cornerstone of clinical governance and continuous quality improvement. When used effectively, it supports learning, strengthens systems, and reduces the risk of patient harm.

What Is Incident Reporting?

The Australian Commission on Safety and Quality in Healthcare (the Commission) defines clinical incidents as “an event or circumstance that resulted, or could have resulted, in unintended or unnecessary harm to a patient or consumer; or a complaint, loss or damage.” Examples of clinical incidents include:

• Medication errors (prescribing, dispensing, administration, or monitoring);
• Patient falls or pressure injuries;
• Delays or failures in diagnosis or treatment;
• Documentation or handover errors;
• Procedural errors;
• Equipment or system failures; and
• Inappropriate treatment.

The most serious patient incidents are classified as sentinel events. Sentinel events are those that are completely avoidable and result in serious harm or death of a patient.

In Australian hospitals, incidents are reported through local electronic reporting systems and managed within organisational clinical governance frameworks. Incident reporting aligns with the National Safety and Quality Health Service (NSQHS) Standards, particularly the Clinical Governance, Medication Safety, Communicating for Safety, and Comprehensive Care standards.

Near Misses

A near miss is an incident that did not cause harm. This may be because it was identified and corrected in time, or because circumstances prevented harm. Examples of near misses include:

• A pharmacist identifying an incorrect dose before dispensing;
• A nurse detecting a mismatch between a medication order and the patient;
• A doctor identifying a prescribing error during chart review; and
• A clinician recognising incorrect equipment settings before use.

Near misses are just as important to report as incidents causing harm. The root cause of near misses and adverse clinical incidents are likely similar. Therefore, reporting near misses can identify vulnerabilities in systems and processes and provide an opportunity to improve safety before a patient is affected.

A further consideration for reporting near misses is that only a small proportion of incidents lead to adverse events. Therefore, only reporting events that led to serious outcomes provides insufficient data for analysis.

The Commission encourages the reporting of near misses, emphasising that they should be viewed as opportunities for improvement.

Why Reporting Matters

Reporting incidents and near misses is important to:

• Improve patient safety and care quality.
  • Incident and near miss reports allow organisations to identify patterns, trends, and high‑risk areas. This information supports system-level improvements, e.g. changes to policies, workflows, or electronic systems, and the implementation of education programs.
• Support a just and learning culture.
  • Australian healthcare organisations promote a just culture, where staff are encouraged to report incidents without fear of blame or punishment. The focus is on understanding what went wrong and why, rather than who was involved.
• Facilitate learning across disciplines.
  • Many incidents involve multiple points in the care pathway. Reporting enables shared learning across medical, nursing, pharmacy and other allied health teams.
• Meet professional and regulatory expectations.
  • All healthcare professionals have ethical and professional obligations to promote patient safety.
  • Incident reporting supports compliance with NSQHS Standards and organisational risk management processes.

Common Barriers to Reporting

Underreporting of clinical events remains a problem, particularly for near misses. One study found that only 13% of medication events are reported.

Barriers to reporting may include:

• Fear of blame, disciplinary action, or reputational impact;
• Time pressures and competing clinical priorities;
• Belief that the incident was minor;
• Uncertainty about what should be reported; and
• Lack of feedback on submitted reports.

In one Australian study, lack of feedback was the most commonly stated barrier for reporting (57.7% for doctors and 61.8% for nurses). Providing feedback to healthcare professionals in the form of newsletters and discussions at departmental meetings has been found to increase reporting rates. Timely and meaningful feedback should also be provided to patients and carers, as appropriate.

Responsibilities

Frontline clinicians have a number of important roles and responsibilities in incident management, including:

1. Recognising reportable events

• All clinicians should report
  • Incidents that resulted in patient harm;

• • Near misses with the potential for harm;
  • Recurrent unsafe conditions or system issues; and
  • Errors intercepted at any stage of care.

2. Contributing to high-quality reports

• Effective incident reports should be:
  • Objective and factual – describe what happened, while avoiding assumptions or judgments;

• • Clear and specific – include relevant details such as timing, location, and contributing factors; and
  • Timely – submitted as soon as practicable after the event.
• Reports should focus on system factors (e.g. communication gaps, workload, design of charts or electronic systems) rather than individual performance.

3. Escalating Immediate Risks

• If an incident presents an ongoing or immediate risk to patient safety, concerns should be promptly escalated through clinical and managerial pathways, in addition to completing an incident report.

4. Learning from near misses

• Near misses are powerful learning tools as they can reveal system weaknesses without patient harm.
• Learning from near misses involves:
  • Reviewing reports to identify recurring themes or trends;

• • Analysing contributing factors such as interruptions, unclear documentation, or handover issues;
  • Implementing targeted improvements (e.g. standardised processes, decision support, double-checks); and
  • Sharing lessons learned with clinical teams to prevent recurrence.
• Feedback to staff about changes resulting from these reviews is critical. When clinicians can see that reporting leads to real improvements, engagement and reporting rates increase.

5. Building a strong reporting culture

• Clinicians can contribute to a strong reporting culture by supporting colleagues, discussing safety concerns openly, and reinforcing the fact that reporting is a professional responsibility and a positive action.
• Healthcare organisations and leaders can also support effective incident reporting by:
  • Promoting psychological safety and a just culture;
  • Providing education on incident and near miss reporting;
  • Ensuring reporting systems are easy to access and use;
  • Communicating outcomes and improvements arising from reports; and
  • Encouraging multidisciplinary review and learning.

Conclusion

Incident reporting and learning from near misses are essential to the provision of safe, high‑quality care. Nurses, doctors, and pharmacists each bring unique perspectives to identifying risks and improving systems. By reporting incidents and near misses, clinicians contribute to shared learning, stronger systems, and better outcomes for patients.

Every incident report, regardless of harm, has the potential to prevent future incidents and improve care.

Further information on incident management, including specific resources published by states and territories, are available from the Commission.