{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/capture-the-near-miss-while-the-evidence-still-exists",
  "id": "MHC-D-RESEARCH-1267",
  "version": "0.1.0",
  "title": "Capture the near miss while the evidence still exists",
  "summary": "A near miss is most useful before it turns into a polished story.",
  "kind": "protocol",
  "body": "Record the event before memory and the system state drift. Capture what was intended, what actually happened, when the deviation became visible, what could have happened, and which logs, messages, files or observations still preserve the sequence. Keep description separate from explanation. Reporting creates evidence for review; it is not evidence that the risk has already been reduced.",
  "limits": [
    "Do not turn every harmless variation into an investigation. Prioritize credible consequence, recurrence or evidence that an important control was bypassed or nearly failed."
  ],
  "topics": [
    "union-error-prevention-weak-signals"
  ],
  "intents": [],
  "source_ids": [
    "RS-68FF51A7951C10DC",
    "RS-2EA215EDE3EC0E64",
    "RS-D0175F3DBA3A507B"
  ],
  "evidence": [
    {
      "claim": "OSHA recommends investigating close calls and near misses to identify underlying hazards, contributing causes and program shortcomings, and grouping similar events to find trends.",
      "source_id": "RS-68FF51A7951C10DC",
      "role": "supports",
      "note": "The guidance concerns occupational safety. The same record structure may be useful elsewhere, but the regulatory context does not transfer.",
      "locator": "Hazard Identification and Assessment; Conduct incident investigations"
    },
    {
      "claim": "A 2022 scoping review found limited evidence that near-miss reporting and learning itself improves patient safety, so reporting should not be treated as proof that risk has fallen.",
      "source_id": "RS-2EA215EDE3EC0E64",
      "role": "limits",
      "note": "The review concerns patient safety and does not test every type of operational near-miss program.",
      "locator": "PSNet summary"
    },
    {
      "claim": "AHRQ's CANDOR guide frames adverse-event and near-miss investigation around preventing future events through systems review rather than assigning blame.",
      "source_id": "RS-D0175F3DBA3A507B",
      "role": "supports",
      "note": "A systems approach does not remove individual accountability for reckless or knowingly unsafe behavior.",
      "locator": "A Systems Approach"
    }
  ],
  "use_when": [
    "Something almost went wrong, was caught just in time or reached an unsafe state without the full consequence."
  ],
  "avoid_when": [
    "Do not turn every harmless variation into an investigation. Prioritize credible consequence, recurrence or evidence that an important control was bypassed or nearly failed."
  ],
  "example": "A bulk update targeted the correct file but the wrong environment was selected; a preview exposed the mismatch before commit. Save the selection, preview and timestamps before changing anything.",
  "check": "Another reviewer can reconstruct the deviation and the detection point from preserved evidence without relying on the operator's memory.",
  "steps": [
    "Another reviewer can reconstruct the deviation and the detection point from preserved evidence without relying on the operator's memory."
  ],
  "sources": [
    {
      "id": "RS-68FF51A7951C10DC",
      "title": "Safety Management - Hazard Identification and Assessment",
      "url": "https://www.osha.gov/safety-management/hazard-identification"
    },
    {
      "id": "RS-2EA215EDE3EC0E64",
      "title": "The value of learning from near misses to improve patient safety: a scoping review",
      "url": "https://psnet.ahrq.gov/issue/value-learning-near-misses-improve-patient-safety-scoping-review"
    },
    {
      "id": "RS-D0175F3DBA3A507B",
      "title": "System-Focused Event Investigation and Analysis Guide",
      "url": "https://www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html"
    }
  ],
  "relations": [
    {
      "from": "MHC-D-RESEARCH-1267",
      "to": "MHC-D-RESEARCH-1268",
      "type": "useful_with",
      "url": "/knowledge/ask-what-stopped-the-near-miss-from-becoming-harm"
    }
  ],
  "collections": [
    {
      "id": "RC-4BAD27B85771C63B",
      "title": "Catch weak signals before they become expensive errors",
      "url": "/collections/catch-weak-signals-before-they-become-expensive-errors"
    }
  ]
}