Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

OBJECTIVE (1) To determine the incidence of near-miss, maternal death and mortality index; (2) to compare near-miss cases as per WHO criteria with that of maternal mortality; and (3) to study the causes of near-miss and maternal deaths. STUDY DESIGN Retrospective cohort study. SETTING Shri Vasantrao Naik Govt. Medical College, Yavatmal, India. STUDY POPULATION All cases of near-miss as pe...

OBJECTIVES To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. STUDY DESIGN We conducted a cross-sectional study in 35 district, provincial and tertiary hospitals over 5 months...

In developed countries the Maternal Mortality Ratio’s (MMR) are low. To get a large enough sample to identify trends in the quality of maternal health care or of the diseases causing maternal deaths takes anything from 3 to 10 years. The information might be out of date due to new developments and discoveries by the time the information is published. Further, the circumstances related to a mate...

This paper describes the potential contribution of near-miss management systems to improving company profitability and reducing the frequency and severity of major industrial accidents. The near-miss concept has long been understood in both manufacturing and finance, as several examples in this paper illustrate. However, what has been largely missing is the integration of near-miss management i...

AIM To determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre. METHODS Retrospective facility-based review of cases of near-miss and maternal death which occurred between 1 January 2002 and 31 D...

BACKGROUND MMR has always been recognized as an important indicator of quality of health services. The MMR in India has so far not reached up to the required MDG 2015. If we look into this matter with the eagle's eye view, then there are certain gray areas which need attention. For this, it is not the maternal mortality but the maternal near miss which has to be focused. OBJECTIVES To audit t...