Publication Date
Spring 2026
Degree Type
Doctoral Project
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
First Advisor
Lisa Walker-Vischer
Keywords
Near-miss events, high-acuity intensive care units (ICUs), Structured educational intervention
Abstract
Near-miss events, defined as errors intercepted before reaching the patient, offer valuable opportunities for learning and prevention, particularly in high-acuity intensive care units (ICUs). Despite the availability of electronic reporting systems and national emphasis on patient safety, near-miss reporting remains inconsistent in many critical care settings. This Doctor of Nursing Practice (DNP) quality improvement project evaluated the impact of a structured educational intervention on near-miss reporting within a cardiovascular intensive care unit (CVICU) at a large academic medical center. A single-group pre–post design was used to examine changes in reporting trends following a three-week intervention that included staff education, leadership engagement, and reinforcement strategies. Data sources included baseline safety culture measures, knowledge assessments, and aggregated near-miss reporting data obtained from the electronic reporting system. A total of 20 nurses participated, representing 11.8% of the unit staff. Following the intervention, near-miss reporting increased from 17% in December to 24% in January, with a subsequent rate of 22% in March, indicating overall improvement despite some variability. Knowledge assessment scores remained unchanged at 100%, suggesting that awareness of near-miss concepts was already present. Findings indicate that reporting behavior is influenced more by workflow demands, psychological safety, and unit culture than by knowledge alone. These results highlight the importance of sustained leadership support and integration of reporting into routine practice to promote a non-punitive safety culture. As a quality improvement initiative, ongoing reinforcement is necessary to maintain progress and support long-term cultural change in high-acuity clinical environments.
Recommended Citation
Sanchez-Lozada, Rosalud H., "Increasing Near-Miss Reporting: An Evidence-Based Approach" (2026). Doctoral Projects. 219.
DOI: https://doi.org/10.31979/etd.vem2-wtuk
https://scholarworks.sjsu.edu/etd_doctoral/219
