Learning from incidents and near misses
Patient safety isn’t only about responding when something goes wrong. Often, it’s about noticing risks early, reflecting on near misses, and making small changes that reduce the chance of harm in the future
That way of working sits at the heart of Principle B of the Code of Professional Practice, which requires chiropractors to “ensure safety and quality in clinical practice.” Principle B recognises that safe care is supported by everyday systems, sound judgement, and a willingness to learn, including learning from situations that could have caused harm, even if they didn’t.
This month’s CPD prompt invites you to reflect on how you identify and learn from incidents and near misses in your own practice, and how that learning helps you strengthen safety and improve the quality of care you provide.
Why near misses matter
Near misses can be easy to dismiss. No one was harmed, the situation passed, and the day moved on. But they can offer valuable insight into how risks arise, whether that’s through the physical environment, communication, decision‑making, or the way systems work together in practice.
Principle B makes clear that learning from these moments is part of professional responsibility. The Code highlights the importance of recognising incidents that “have the potential” to affect safety, and of using suitable systems to support learning, not only for individual reflection, but to help the wider profession reduce future risks.
Reflecting on near misses can help you:
- spot patterns you might otherwise miss
- test whether your current systems are working as intended
- make proportionate changes before harm occurs
All of this supports a culture of safety — one that focuses on prevention, openness, and continuous improvement.
Learning beyond your own practice
Learning doesn’t have to be limited to what happens in your own clinic. Many chiropractors also choose to learn from shared professional experience, including themes and insights arising from reported incidents.
One way this happens is through CPiRLS - the Chiropractic Patient Incident Reporting and Learning System. CPiRLS is an independent, confidential and anonymous reporting and learning forum that allows chiropractors to share patient safety incidents, near misses and potential risks, with a focus on learning rather than blame.
By looking at reported cases and safer practice notices, chiropractors can see how risks arise in different contexts and consider whether similar vulnerabilities exist in their own practice. For some, this kind of shared learning can prompt useful reflection or small changes that strengthen safety systems.
Engaging with CPiRLS, whether by reporting, reading cases, or reflecting on published themes, can be one way of supporting the expectations set out in Principle B, particularly around learning from incidents and contributing to safer practice.
Linking this to your CPD reflection
This year’s CPD focused reflection asks registrants to reflect on:
- how they prevent potential safety incidents
- how they learn when things do not go as planned
- how they improve the quality and accessibility of care over time
Learning from incidents and near misses — including learning drawn from shared professional insight — can provide strong, practical examples for reflection. That learning might come from something you experienced directly, something you noticed and addressed early, or something that made you pause and review your own systems after reading about a similar situation elsewhere.
What matters most is not the seriousness of the incident, but what you learned, what you changed, and how that learning supports safer, higher‑quality care.
Reflective prompts to consider
You might find it helpful to reflect on questions such as:
- What risks or near misses have stood out to you this year, and how did you recognise them?
- What did those experiences tell you about your systems, environment, or decision‑making?
- What changes — even small ones — have you made as a result?
- Has learning from shared professional experience (such as CPiRLS cases or safety notices) influenced how you think about risk in your own practice?
These kinds of reflections align closely with both Principle B and the aims of this year’s CPD focus on safety and quality.
Further resources
