Nurses’ clinical intervention and barcode medication scanning emerged as the two biggest safeguards preventing patient harm in intensive care units at Los Angeles-based Cedars-Sinai, according to a study published in The Joint Commission Journal on Quality and Patient Safety.
Researchers analyzed 288 near misses reported in 2024 from inpatient critical care units at the health system. Using a human factors approach, they identified 396 contributing factors to these near misses, along with the interventions that prevented them from escalating to patient harm.
Nursing interventions accounted for the largest share of near-miss prevention, stopping 41% of events, followed by barcode medication scanning at 31%.
“Nurses’ actions included following up on irregular orders, conducting routine medication safety checks and facilitating communication among care teams,” study author Tara Cohen, PhD, a research scientist and associate professor in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai, said in a Feb. 3 news release. “Their clinical judgment, experience and adherence to safety routines were instrumental in identifying potential threats before they reached patients.”
The authors conclude that systematically analyzing near-miss events through a human factors lens can help hospitals identify underlying workflow and system vulnerabilities and strengthen the front-line interventions and safeguards that prevent errors from reaching patients in high-risk ICU settings.
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