DOI: 10.36347/sjams.2017.v5i08.029

Pages: 3108-3110

A “near miss” is an unexpected incident related to system or process failure which could have caused damage, but didn't. Near-miss provides insight into potential failures and weaknesses in the system. It can be a powerful tool to reduce risk and improve system reliability. We present a near-miss case which occurred while dismantling a patient care area without informing others concerned. Communication failure is most common cause of accidents in any organization. Although effective communication is a very simple and cost-effective measure to prevent failures yet it is most commonly neglected measure due to which many adverse and catastrophic events have occurred. This incident will prompt hospitals to document and communicate all necessary information for patient, public, staff and equipment safety.