What Is a Physician’s Obligation to Disclose ‘Near-Miss’ and ‘No-Harm’ Events to Patients?

But what is an otolaryngologist’s responsibility to disclose what are termed “near misses” and “no-harm events?” One could certainly pose the argument that, because these events didn’t result in actual harm to the patient, it shouldn’t be necessary to disclose. After all, where there is “no harm,” there is “no fault.” Events such as these, whether acts of omission or commission, occur fairly commonly and, depending on the proximity of the event to a true harm, may not rise to a patient’s awareness. Why should otolaryngologists disclose something that wasn’t really a “happening”? The answer lies in three domains: our professional duties to the patient, our ethical obligations to the patient, and our fiduciary responsibilities to society.

Near Misses and No-Harm Events

We all understand the concepts of near misses and no-harm errors/events. A near miss is an event that didn’t reach the patient because of timely intervention or luck. A no-harm event reached the patient in some manner but caused no real harm. This isn’t to say that the same event might not cause harm if repeated in the future with the same or another patient. The nuanced difference between the two types of events isn’t necessarily significant with respect to the need to disclose, as either may have the potential for repetition and a different outcome if not properly addressed. Although we wish to never have a near miss or no-harm event, if one does occur, we are obliged to act to prevent any further occurrences, and disclosure is the first step in prevention.

Near misses and no-harm events occur quite regularly in life: We or someone else may catch us when we trip, preventing a fall; another car swerves into our lane on the highway and we brake suddenly because no one is close behind us; we’re about to say something unseemly about a co-worker when we notice they’re entering the room. We read about near misses by aircraft and watch videos of trains nearly hitting cars on the tracks.

These events occur not only in life, but also in patient care, and we must always be on the lookout for them. We cannot become lackadaisical about their potential for occurring—think “Murphy’s Law of Medicine”: If something can go wrong it will, and if it doesn’t, we don’t know about it yet. The aviation industry has been a leader in identifying, preventing, and dealing with near misses. Identification, disclosure, and discussion that lead to changes in protocols, with a subsequent feedback loop, are fundamental to root–cause analysis and risk reduction. The same process applies well to healthcare, where patients’ health is at stake.