When Subtle Changes Matter: My Experience with a Near Miss in Healthcare
By Kristen Stuart, RN — ClearPath Concierge & Private Duty Nursing LLC
What Is a “Near Miss” in Healthcare?
In healthcare, a near miss is an event that could have resulted in serious harm—but didn’t, often because it was recognized just in time.
These moments are rarely dramatic at first.
They are quiet. Subtle. Easy to overlook.
And sometimes… they happen slowly.
My Story: When Something Didn’t Feel Right
There was a time when I wasn’t the nurse in the room.
I was the patient.
After a surgery, everything initially seemed to be going as expected. Nothing alarming. Nothing urgent. Just recovery.
But then, something began to change.
Not all at once—but gradually.
I remember feeling off in a way that was hard to explain. I asked my post op nurse to keep my Pulse oximeter on because my oxygen level wouldn’t increase past 92% on oxygen. That number doesn’t always bother you in the PACU but for some reason, it didn’t feel right to me. I was then transferred to a floor to recover.
Then came the physical signs four hours later:
I became pale—almost ghost-like
I felt nauseated, like I might vomit
My heart rate was climbing
My blood pressure was slowly dropping
Individually, none of these felt like a crisis.
But together… they were telling a story.
The Slow Danger of Internal Bleeding
What I was experiencing was internal bleeding.
Not rapid. Not obvious.
But slow enough to quietly change my vital signs over time.
This is what makes situations like this so dangerous.
There is no dramatic moment at the beginning.
No immediate alarm.
Just a pattern—one that can be missed if no one is watching closely.
A CT scan ultimately confirmed what my body had been signaling all along: there was internal bleeding.
And at that point… we were getting close to it being too late.
Thankfully, I was taken in time to have an emergent surgery to cauterize the area that was causing the bleeding to occur and I also had several blood transfusions. I later developed an lieus. Regardless, I was alive.
What a Near Miss Really Looks Like
When people think of medical emergencies, they often picture something sudden and obvious.
But many near misses don’t always look like that.
They look like:
A trend, not a single number
A patient who “just doesn’t look right”
Vital signs that are technically within range—but not normal for that person
A subtle shift in color, energy, or awareness
In my case, it wasn’t one number that told the story.
It was the combination:
Rising heart rate
Falling blood pressure
Pale skin
Nausea
And that unmistakable internal sense that something was wrong
The Power of Pattern Recognition
As a nurse, this experience reinforced something I have always believed:
Vital signs are not just numbers. They are signals.
But they only make sense when you look at:
The patient’s baseline
The trend over time
The physical presentation
And clinical intuition
Because sometimes the question isn’t:
“Is this number critical?”
It’s:
“Is this normal for this patient? Is this a new patter?”
Why This Matters for Patients and Families
Many patients are discharged home still in a vulnerable state. Many times, a patient in the hospital needs another set of eyes and ears to serve as advocate in the hospital for them while they recover.
They are told what to expect—but not always what to watch for.
And often, the earliest warning signs are subtle:
Increasing fatigue
Dizziness
Changes in color
Feeling faint or nauseated
Small but consistent shifts in vital signs
Without trained eyes on those patterns, these early clues can be missed.
The Role of RN-Led Care
This is where experienced nursing care makes a difference.
Not just checking boxes.
Not just taking vitals.
But interpreting the full picture.
At ClearPath, this is what we do:
Monitor trends—not just single readings
Recognize early warning signs
Advocate when something doesn’t feel right
Support patients and families before a situation escalates
Because sometimes the difference between a complication and a crisis…
is simply catching it sooner.
Final Thoughts
My experience as a patient reminded me of something deeply important:
Healthcare is not just about reacting to emergencies.
It’s about recognizing the quiet moments before they happen.
Near misses are not rare. They are often just unrecognized patterns waiting to be seen.
And sometimes…listening to the patient, watching closely, and trusting clinical instinct can make all the difference.
If you or a loved one are recovering from surgery or are in the hospital and want an experienced RN to monitor for subtle changes and provide proactive, personalized care:
ClearPath Concierge & Private Duty Nursing LLC is RN-led, private-pay care designed to help you feel confident, supported, and safe at home.