Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies

Mehmet Zeki Öğüt; Onur Ağ

Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies

Abstract

Aims: Complex workflows, time pressure, and communication problems within surgical teams pose significant risks to patient safety during surgical care processes. Near-miss events are critical incidents that reveal underlying safety problems within a system before patient harm occurs. This study aimed to evaluate healthcare workers’ experiences with near-miss events, associated risk factors, and perspectives on prevention strategies in surgical settings. Methods: This single-center, cross-sectional survey study included healthcare workers involved in surgical care processes at Elazığ Fethi Sekin City Hospital. Electronic questionnaires were administered between May 1 and 13, 2026. Data were analyzed using descriptive statistical methods. Results: A total of 221 healthcare workers participated in the study. Overall, 72.9% of the participants reported experiencing at least one near-miss event within the previous 12 months. Near-miss events were most frequently encountered in communication-related situations (44.8%), equipment/material problems (41.2%), and medication administration (29.4%). The main contributing factors were heavy workload (67.0%), distraction (55.7%), insufficient staffing (53.8%), time pressure (48.9%), fatigue or sleep deprivation (48.4%), and communication deficiencies (45.2%). In the single-choice analysis, heavy workload was the most prominent risk factor. Participants identified heavy workload, fear of blame, and time constraints as the main barriers to near-miss event reporting. Among the prevention strategies, the highest mean effectiveness score was assigned to reducing and balancing workload (3.63/5), followed by strengthening team communication and ensuring strict adherence to standardized protocols. Conclusion: Near-miss events in surgical processes are common and largely preventable patient safety issues. Reducing workload, strengthening team communication, and developing accessible and non-punitive reporting systems appear to be key strategies for improving surgical safety.

Keywords

Supporting Institution

None.

Project Number

Not applicable

Ethical Statement

This study was approved by the Non-Interventional Clinical Research Ethics Committee of Elazığ Fethi Sekin City Hospital (Date: 16.04.2026, Decision No: 2026/28-17).

Thanks

The authors would like to thank all healthcare professionals who voluntarily participated in this study and shared their valuable experiences and perspectives.

References

Anderson O, Davis R, Hanna GB, Vincent CA. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-262. doi:10.1016/j.amjsurg.2012.11.009
Duclos A, Frits ML, Iannaccone C, et al. Safety of inpatient care in surgical settings: cohort study. BMJ. 2024;387:e080480. doi:10.1136/bmj-2024-080480
Zegers M, de Bruijne MC, de Keizer B, et al. The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Saf Surg. 2011;5:13. doi:10.1186/1754-9493-5-13.
Stucky CH, Michael Hartmann J, Yauger YJ, et al. Surgical safety does not happen by accident: learning from perioperative near miss case studies. J Perianesth Nurs. 2024;39(1):10-15. doi:10.1016/j.jopan.2023.06.095
Heideveld-Chevalking AJ, Calsbeek H, Damen J, Gooszen H, Wolff AP. The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 near-misses and adverse events. Patient Saf Surg. 2014;8(1):46. doi:10.1186/preaccept-1149944930147258
Davies C, Read I, Sucharitkul P, Mouton R, Hinchliffe R. Effectiveness of interventions delivered within inpatient perioperative care in adults undergoing surgery: scoping review of systematic reviews. BJS Open. 2026;10(2):zrag013. doi:10.1093/bjsopen/zrag013
Sheikhtaheri A. Near misses and their importance for improving patient safety. Iran J Public Health. 2014;43(6):853-854.
Ragusa PS, Bitterman A, Auerbach B, Healy WA. Effectiveness of surgical safety checklists in improving patient safety. Orthopedics. 2016; 39(2):e307-e310. doi:10.3928/01477447-20160301-02

Takahashi K, Fukatsu T, Oki S, et al. Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution. J Anesth. 2023;37(1):49-55. doi:10.1007/s00540-022-03127-7
Curtis NJ, Dennison G, Brown CSB, et al. Clinical evaluation of intraoperative near misses in laparoscopic rectal cancer surgery. Ann Surg. 2021;273(4):778-784. doi:10.1097/SLA.0000000000003452
Tinsley CH, Dillon RL, Cronin MA. How near-miss events amplify or attenuate risky decision making. Manage Sci. 2012;58(9):1596-1613. doi:10.1287/mnsc.1120.1517
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. doi:10.1056/NEJMsa0810119
Alfayez A, Althumairi A, Aljuwair M, Althukair D, Aljabri D. Factors affecting patient safety near miss reporting: a systematic review. J Adv Nurs. 2026;82(3):2022-2035. doi:10.1111/jan.70033
Kavanagh R, Ward ME. What is known about near miss events in the operating room? A systematic review of studies of mixed methods design. Ir J Med Sci. 2025;194(1):297-310. doi:10.1007/s11845-024-03822-2
Woodier N, Burnett C, Sampson P, Moppett I. Patient safety near misses: still missing opportunities to learn. J Patient Saf Risk Manag. 2023;29(1):47-53. doi:10.1177/25160435231220430
Almansour H. Barriers preventing the reporting of incidents and near misses among healthcare professionals. J Health Manag. 2023;26(1):78-84. doi:10.1177/09720634231167031
Yan M, Wang M, Al-Hakim L. Barriers to reporting near misses and adverse events among professionals performing laparoscopic surgeries: a mixed methodology approach. Surg Endosc. 2021;35(12):7015-7026. doi:10.1007/s00464-020-08215-x
Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. J Surg Res. 2017;221:336-342. doi:10.1016/j.jss.2017.08.005
Yang Y, Liu H. The effect of patient safety culture on nurses’ near-miss reporting intention: the moderating role of perceived severity of near misses. J Res Nurs. 2021;26(1-2):6-16. doi:10.1177/1744987120979344
Braillon A, Naudet F. STROBE and pre-registration of observational studies. BMJ. 2023;380:p90. doi:10.1136/bmj.p90
Vandenbroucke JP, Elm EV, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Ann Intern Med. 2007;147(8):W163-W194. doi:10.7326/0003-4819-147-8-200710160-00010-w1
Eysenbach G. Correction: improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2012;14(1):e8. doi:10.2196/jmir.2042
Ma LY, Shan RF, Lu Y, Cong LY, Gu HY. Systematic risk analysis and mitigation strategies for near-miss events in interventional operating room nursing. Risk Manag Healthc Policy. 2025;18:239-248. doi:10.2147/RMHP.S495603
Ruddy RM, Chamberlain JM, Mahajan PV, et al. Near misses and unsafe conditions reported in a Pediatric Emergency Research Network. BMJ Open. 2015;5(9):e007541. doi:10.1136/bmjopen-2014-007541
Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of human performance deficiencies associated with surgical adverse events. JAMA Netw Open. 2019;2(7):e198067. doi:10.1001/jamanetworkopen.2019.8067
Siu J, Maran N, Paterson-Brown S. Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. Surgeon. 2016;14(3):119-128. doi:10.1016/j.surge.2014.06.005
Weprin SA, Meyer D, Li R, et al. Incidence and OR team awareness of near-miss and retained surgical sharps: a national survey on United States operating rooms. Patient Saf Surg. 2021;15(1):14. doi:10.1186/s13037-021-00287-5
Eygi E, Balkaya AN, Bayrakçı O. Evaluation of the approach to near-miss events in anesthesia care. Harran Univ Tıp Fak Derg. 2025;22(3):493-499. doi:10.35440/hutfd.1752361
Kwak SK, Ahn JS, Kim YH. The association of job stress, quality of sleep, and the experience of near-miss errors among nurses in general hospitals. Healthcare (Basel). 2024;12(6):699. doi:10.3390/healthcare12060699
Elkhider S, Savage BM. Missing chances to learn: a case study of barriers to near-miss reporting in a hospital. Bus Process Manag J. 2019;26(3):721-735. doi:10.1108/BPMJ-03-2019-0110
Vrbnjak D, Denieffe S, O’Gorman C, Pajnkihar M. Barriers to reporting medication errors and near misses among nurses: a systematic review. Int J Nurs Stud. 2016;63:162-178. doi:10.1016/j.ijnurstu.2016.08.019
Anderson MJ, Stephens WA, Levy BE, Newcomb MR, Harris AM. Barriers to incident reporting by physicians: a survey of surgical residents and attending physicians. Cureus. 2024;16(6):e62850. doi:10.7759/cureus.62850
Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med. 2023;188(7-8):usac115. doi:10.1093/milmed/usac115
Dwidar MM, Fakhry SF, Abdel-Hamed LA. Just culture and its influence on nurse interns’ willingness to report near-miss events: a cross-sectional study in five Egyptian university hospitals. BMC Nurs. 2025;24(1):1397. doi:10.1186/s12912-025-03979-w
Moon JY, Welp C, Nold M, et al. Optimizing event reporting to drive a culture of learning and safety: a system-based approach to mitigating harm through near-miss and no-harm reporting. J Patient Saf. 2026; 22(1):86-92. doi:10.1097/PTS.0000000000001424

Details

Primary Language

English

Subjects

General Surgery, Surgery (Other)

Journal Section

Research Article

Authors

Mehmet Zeki Öğüt ^*
0000-0002-7698-9586
Türkiye

Onur Ağ
0000-0002-6546-6755
Türkiye

Publication Date

July 16, 2026

Submission Date

June 5, 2026

Acceptance Date

July 11, 2026

Published in Issue

Year 2026 Volume: 8 Number: 4

IZ

https://izlik.org/JA88EY39JX

Cite

RIS / Bibtex

APA

Öğüt, M. Z., & Ağ, O. (2026). Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies. Anatolian Current Medical Journal, 8(4), 804-810. https://izlik.org/JA88EY39JX

AMA

1.Öğüt MZ, Ağ O. Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies. Anatolian Curr Med J / ACMJ / acmj. 2026;8(4):804-810. https://izlik.org/JA88EY39JX

Chicago

Öğüt, Mehmet Zeki, and Onur Ağ. 2026. “Near-Miss Events in Surgical Processes: Healthcare Workers’ Experiences, Risk Factors, and Prevention Strategies”. Anatolian Current Medical Journal 8 (4): 804-10. https://izlik.org/JA88EY39JX.

EndNote

Öğüt MZ, Ağ O (July 1, 2026) Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies. Anatolian Current Medical Journal 8 4 804–810.

IEEE

[1]M. Z. Öğüt and O. Ağ, “Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies”, Anatolian Curr Med J / ACMJ / acmj, vol. 8, no. 4, pp. 804–810, July 2026, [Online]. Available: https://izlik.org/JA88EY39JX

ISNAD

Öğüt, Mehmet Zeki - Ağ, Onur. “Near-Miss Events in Surgical Processes: Healthcare Workers’ Experiences, Risk Factors, and Prevention Strategies”. Anatolian Current Medical Journal 8/4 (July 1, 2026): 804-810. https://izlik.org/JA88EY39JX.

JAMA

1.Öğüt MZ, Ağ O. Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies. Anatolian Curr Med J / ACMJ / acmj. 2026;8:804–810.

MLA

Öğüt, Mehmet Zeki, and Onur Ağ. “Near-Miss Events in Surgical Processes: Healthcare Workers’ Experiences, Risk Factors, and Prevention Strategies”. Anatolian Current Medical Journal, vol. 8, no. 4, July 2026, pp. 804-10, https://izlik.org/JA88EY39JX.

Vancouver

1.Mehmet Zeki Öğüt, Onur Ağ. Near-miss events in surgical processes: healthcare workers’ experiences, risk factors, and prevention strategies. Anatolian Curr Med J / ACMJ / acmj [Internet]. 2026 Jul. 1;8(4):804-10. Available from: https://izlik.org/JA88EY39JX