Near Misses as Signals of System Vulnerability in Thoracic Surgery: A Narrative Review on Quality Improvement and Patient Safety

Near misses-clinical events that could have resulted in patient harm but did not-are increasingly recognized as critical yet underutilized sources of insight in surgical quality improvement. In thoracic surgery, where procedures are physiologically demanding and care pathways are highly interdependent, near misses frequently precede major complications and expose latent system vulnerabilities rather than isolated technical errors. A structured narrative review methodology was employed, including a targeted literature search of major biomedical databases and thematic synthesis of relevant studies. This narrative review synthesizes evidence from patient safety science, surgical quality literature, and thoracic surgery-specific outcomes research to examine how near misses can be systematically leveraged to improve care. We discuss the transition from individual-centered explanations of adverse events to system-based models that emphasize human factors, communication, escalation pathways, and organizational culture. Particular attention is given to contemporary quality frameworks such as failure to rescue and textbook outcome, which highlight the importance of early recognition, coordinated response, and recovery from complications rather than complication avoidance alone. We further explore the central role of psychological safety and leadership behaviors in enabling meaningful learning from near misses. By reframing near misses as actionable data rather than anecdotal "close calls," quality improvement emerges as a core professional responsibility in thoracic surgery. We conclude that excellence in thoracic surgery should be defined not by the absence of complications, but by the capacity of surgical systems to learn, adapt, and prevent future harm.