Qualitative study on the ICU nurses' cognition of near-miss events in the transport of critically ill patients

CHEN Juan; CAI Zheyi; CAI Yahong

doi:10.3969/j.issn.1674-3768.2025.06.001

Abstract：Objective To understand nurses' cognition of near-miss events in the transfer of critically ill patients,so as to provide a reference for promoting its safe management.Methods A phenomenological research method was applied to conduct semi-structured in-depth interviews with 13 intensive care unit(ICU)nurses in the first affiliated hospital of Hunan university of Chinese medicine,and the Colaizzi 7-step analysis method was used to analyze the interview data and refine the themes.Results A total of five themes were extracted:(1)ICU nurses' insufficient knowledge of critical patients' near-miss transfer,(2)lack of nursing competence,deviation in implementation,and unexpected situational pressures leading to near-miss events,(3)ICU nurses suffering from a complex psychological experience of fear,self-blame,gratitude,and fluke in the face of such events,(4)ICU nurses' concealment and selective help-seeking in response to such events,(5)barriers to ICU nurses' practice of managing such conditions(inappropriate or insufficient allocation of human resources,lack of education and training for nursing managers to deal with the response,no case study and imperfect non-punitive reporting mechanisms).Conclusion ICU nurses' awareness of near-miss events in critical patients' transfer needs to be improved,and managers at all levels need to pay greater attention to and continuously optimize its management and the practice mode,so as to promote its implementation.