{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/ask-what-stopped-the-near-miss-from-becoming-harm",
  "id": "MHC-D-RESEARCH-1268",
  "version": "0.1.0",
  "title": "Ask what stopped the near miss from becoming harm",
  "summary": "A good ending can hide whether the system was protected or merely lucky.",
  "kind": "question",
  "body": "Identify the last thing that interrupted the failure path. Was it a designed safeguard, an independent human check, an unrelated circumstance or pure timing? Then ask whether the same catch would still exist under a different operator, higher load or slightly different sequence. The aim is not to praise or blame the final catcher; it is to understand how much protection actually exists.",
  "limits": [
    "A single near miss cannot establish a control's failure probability. Use the analysis to choose what to verify, redesign or measure next."
  ],
  "topics": [
    "union-error-prevention-weak-signals"
  ],
  "intents": [],
  "source_ids": [
    "RS-00E7F25184BF4AAC",
    "RS-68FF51A7951C10DC",
    "RS-2EA215EDE3EC0E64"
  ],
  "evidence": [
    {
      "claim": "AHRQ safety-engineering guidance recommends combining prospective and retrospective analysis with ongoing surveillance, and notes that workarounds can signal that a process is not functioning well.",
      "source_id": "RS-00E7F25184BF4AAC",
      "role": "supports",
      "note": "The guidance is written for healthcare systems; transfer to knowledge work is at the general system-design level.",
      "locator": "Strategy 1 rationale and opportunities"
    },
    {
      "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"
    }
  ],
  "use_when": [
    "A near miss ended safely and the team is tempted to close it because 'the control worked.'"
  ],
  "avoid_when": [
    "A single near miss cannot establish a control's failure probability. Use the analysis to choose what to verify, redesign or measure next."
  ],
  "example": "A reviewer notices a wrong customer before activation. If review was optional and happened only because that person had spare time, the system should not count it as a reliable barrier.",
  "check": "The review names the actual catching mechanism and whether it is designed, repeatable and independent enough to rely on.",
  "question": "An error reached the final step but happened to be noticed because a colleague walked past the screen. Was the process protected?",
  "sources": [
    {
      "id": "RS-00E7F25184BF4AAC",
      "title": "Engineering Safe Practices Affinity Group",
      "url": "https://www.ahrq.gov/action-alliance/engineering-safety-practice/index.html"
    },
    {
      "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"
    }
  ],
  "relations": [
    {
      "from": "MHC-D-RESEARCH-1268",
      "to": "MHC-D-RESEARCH-1273",
      "type": "useful_with",
      "url": "/knowledge/layer-safeguards-so-one-miss-is-not-the-last-chance"
    }
  ],
  "collections": [
    {
      "id": "RC-4BAD27B85771C63B",
      "title": "Catch weak signals before they become expensive errors",
      "url": "/collections/catch-weak-signals-before-they-become-expensive-errors"
    }
  ]
}