How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

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Analysis and perceived severity of risk influences organizational decisions to anticipated threats. As economic development and technology improve our standards of living, they also create new challenges to conceptualizing concrete and abstract threats. Organizations that face new threats, along with agencies that oversee these organizations, produce tightly coupled systems that increase risks for direct, indirect, and future stakeholders (Perrow, 1999). Natural disasters, political misbehavior, organizational corruption, financial collapse, food and water contaminations, chemical or nuclear accidents, international tension, to name a few, all present risks and challenges. Unfortunately, many of these situations endanger the lives and well-being of persons. The ability of individuals to conceptualize, prioritize, and respond to myriad threats ultimately determines their risk perception and intention to act accordingly. Individuals often exaggerate some risks, while failing to acknowledge the severity of others (Sandman, 1989; Lachlan & Spence, 2007). This study will contribute to the understanding of subjectively constructed threats by examining three specific perceptual crises: A hoax, near miss, and risk misconstrual event. Each of these cases relies on robust newspaper descriptions, content analysis of media, and confirmatory organizational interviews. They are documented through a level of legislative action to determine real and structural changes incurred from perceptual crises. From these investigations this dissertation articulates how perceptual crises challenge organizations and governments, ascertains the viability of actional legitimacy theory, and observes variance in communication challenges between differing crisis contexts. These expectations encompass both applied and theoretical contributions.