Follow the near miss before it becomes normal
Apply high-reliability habits to investigate and act on a near miss without waiting for harm.
Near miss A lifting central-line dressing is found before infection or line contamination occurs. The patient is safe now, so the leadership decision is whether to learn or normalize drift. High reliability Five habits under small pressure Use the near miss to practice preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and resilience. Shortcut No harm, send a reminder. The unit learns before the event reaches the patient. High reliability is built in small moments before harm. 01 Classify 02 Investigate 03 Act 04 Now you try
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