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Semin Med Pract 
2002 Mar;5(1):12-19
The near miss resident conference: understanding the barriers to confronting medical errors
Sorokin R, Claves JL, Kane GC, Gottlieb JE

One Institute of Medicine recommendation for improving patient safety is to establish an institutional culture that encourages members of an organization to work together to identify and learn from medical errors. Motivated by this recommendation, faculty at Thomas Jefferson University Hospital created a morning report conference to provide residents an opportunity to discuss near miss events in a blame-free environment focused on learning from errors. The authors describe the barriers encountered and lessons learned in implementing a monthly near miss conference, as well as the essential criteria for establishing a near miss conference as an effective educational tool.

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