关键词: 患者安全；接近失误；组织学习；风险管理

Abstract: Objective: To evaluate the effect of the near miss organizational learning scheme which was developed based on the 4I Framework of Organizational Learning. Methods: A quasi-experimental research based on the near miss organizational learning scheme in the emergency department was conducted from July to November 2021, and compared the near miss organizational learning behavior and its performance before and after the intervention. Results: After the intervention, the recognition ability of near miss, the intention and conduction of second-order problem solving behavior following near miss, the group level learning performance and organizational learning behavior have been improved. Additionally, we have collected 100 near misses during the intervention which reflected the current status of risk reasonably. Conclusion: This scheme can effectively improve the behavior and effect of near miss organizational learning, and can provide a reference for other medical and health organizations in the future.

Key words: patient safety; near miss; organizational learning; risk management