Reporting a near miss

Question

Complete the statement about a medication event.

While preparing medicines, a nurse sees that a pharmacy label shows ten times the prescribed dose and stops before giving it. The nurse should complete an incident report as agency policy directs because reporting near misses helps the organization find and fix system weaknesses before a client is harmed.

• Blank 1 choices: complete an incident report as agency policy directs / discard the dose and tell no one, since the client was not harmed / mention it privately to a coworker but keep it out of any report / wait to see whether the same error happens again
• Blank 2 choices: reporting near misses helps the organization find and fix system weaknesses before a client is harmed / incident reports are mainly used to decide which staff to discipline / only errors that reach a client need to be reported / a report is required only when a provider asks for one

Answer

Blank 1: complete an incident report as agency policy directs · Blank 2: reporting near misses helps the organization find and fix system weaknesses before a client is harmed

Rationale

A near miss is an error that is caught before it reaches the client. Safety cultures ask staff to report near misses as well as actual errors, because each report can prompt an analysis of why the error happened and lead to changes that protect future clients. The emphasis is on learning about the system, not on punishing the person who reports.