Development and Formative Evaluation of an Innovative National Near-miss Reporting System for Curative Healthcare Institutions in Sri Lanka - SHAPE International Symposium 2025

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Published: Dec 19, 2025
DOI: https://doi.org/10.24083/apjhm.v20i3.5077
Keywords:
Quality Improvement, Patient Safety, Healthcare Near-misses, Near-miss Reporting Systems, Intervention Study, Low- and Middle-Income Countries

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Priyanwada Jayalath
Griffith University
https://orcid.org/0009-0005-5137-6731
Dilantha Dharmagunawardene
Griffith University
https://orcid.org/0000-0002-5457-3117
Samath Dharmaratne
University of Peradeniya, Sri Lanka
Paula Bowman
Queensland University of Technology, QLD, Australia
https://orcid.org/0000-0003-1723-7170
Reece Hinchcliff
Griffith University, Queensland Australia
https://orcid.org/0000-0001-9920-4211

Abstract

Background: Near-misses are errors that have the potential to cause an adverse event but fail to do so because of chance or because they are intercepted. By 2021, Sri Lanka had only established systems for maternal and blood transfusion services.


Methods: A new holistic near-miss reporting system was developed and piloted at a large tertiary hospital in 2022 to guide subsequent nationwide implementation. During the pre-interventional phase, national-level consultative meetings (n=20), key informant interviews (n=10), and focus groups (n=22) were convened with purposively selected representatives of professional colleges, academia, medical administrators, and senior staff of the participating hospital to identify existing methods of reporting near-misses. A near-miss reporting format and guidelines were designed with input from national-level consultative meetings. Training on the new system for medical and nursing officers, periodic reminders to staff, and dissemination of preventive measures for patient safety incidents were implemented as interventions. A pre-post evaluation was conducted to identify the effect of the new system and stakeholders’ views on the potential for nationwide implementation.


Results: Eight near-misses were reported three months following implementation, compared to none prior to implementation. Study participants expressed satisfaction with the new system's user-friendliness, clarity, non-punitiveness, voluntary nature, and confidentiality protection. The system was perceived to be suitable for national implementation following refinements.


Conclusions: This evidence-based near-miss reporting system, combined with the complementary activities implemented in the pilot setting, should now be introduced into additional hospitals before national implementation to further enhance its design, support from stakeholders, and quality and safety impact.

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How to Cite
Jayalath, . M. P., Dharmagunawardene, D. ., Dharmaratne, S. D. ., Bowman , P., & Hinchcliff, R. . (2025). Development and Formative Evaluation of an Innovative National Near-miss Reporting System for Curative Healthcare Institutions in Sri Lanka : - SHAPE International Symposium 2025 . Asia Pacific Journal of Health Management, 20(3). https://doi.org/10.24083/apjhm.v20i3.5077
Issue
Vol. 20 No. 3 (2025)
Section
Conference Articles
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Author Biographies

Priyanwada Jayalath, Griffith University

Dr M P Jayalath is attached to Griffith University, Australia, as a visiting scholar at present. She holds a Master’s degree and a Doctorate in Medical Administration from the Post Graduate Institute of Medicine, University of Colombo, Sri Lanka. She started her career as a clinician and, over time, has transitioned into healthcare management. She has worked as the Deputy Director of Training and Deputy Director of Laboratory Services at the Ministry of Health, and also the Medical Manager of two secondary care health institutions. Her research interests are health systems research, health planning, health policy, medical ethics, and healthcare quality and safety.

Dilantha Dharmagunawardene, Griffith University

Dr. Dilantha Dharmagunawardene is currently a doctoral student at Griffith University, Australia. He completed his Master's and Professional Doctorate in Medical Administration from the Post Graduate Institute of Medicine, University of Colombo, Sri Lanka. He is a board-certified consultant in medical administration and served as the secretary to the Board of Study in Medical Administration. He is the former Director, Training and Director, Medical Services of the Ministry of Health, Sri Lanka. He had more than 50 scientific presentations and publications, including in international peer-reviewed journals.

Samath Dharmaratne, University of Peradeniya, Sri Lanka

Prof S D. Dharmaratne started his career as a clinician after obtaining an MBBS degree and over time, has transitioned into public health. He holds a Master’s degree and a Doctorate in Community Medicine and at present, he is the Director of the Post Graduate Institute of Medical Sciences, University of Peradeniya. He was the immediate past President of the Sri Lanka Medical Association. He has nearly 100 scientific publications, including in international peer-reviewed journals. His research interests are medical statistics, injury prevention, road traffic injury prevention, health economics, epidemiology, non-communicable diseases, nutrition, burden of diseases, and causes of death.

Paula Bowman , Queensland University of Technology, QLD, Australia

Paula has 27 years of experience in the public healthcare sector and 11 years as a senior executive at Queensland Health. She has comprehensive knowledge and understanding of government processes, public health policy, health care quality and governance, health service and workforce planning, and health care funding mechanisms. She has lectured at QUT since 2009 in the Master of Health Management MHM program, coordinating core units in contemporary health management and health leadership and writing and coordinating all units in the health care quality and safety major study area.

Reece Hinchcliff, Griffith University, Queensland Australia

Prof Reece Hinchcliff is currently the Academic Lead and Program Director, Health Services Management at the School of Applied Psychology of Griffith University. He is also an adjunct professor at Queensland University of Technology (QUT). Prof Hinchcliff is a Health Services Researcher who has authored 55 peer-reviewed papers and 15 government reports.

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