Good Catches Worth Sharing: Learning from Near-miss Events

Guest Author: 

Rajiv Rampersaud, RPh, PharmD, Medication Safety Specialist, Institute for Safe Medication Practices Canada (ISMP Canada) 

Introduction

In many cases, potential medication incidents are caught by pharmacy professionals before they reach the patient. According to a National Incident Data Repository Safety Brief, over 73% of the reports received from community pharmacies in Manitoba did not involve an error. Most of these no error reports included near misses.

A near-miss refers to an event that could have resulted in inappropriate medication use or patient harm but was discovered before reaching the patient. Near-miss events are good catches that provide community pharmacies with valuable lessons to support system improvements and enhance patient safety.

Near-miss Event Example

An example of a near-miss event presented in a recent ISMP Canada Safety Bulletin involved incomplete order entry for a medication used for diabetes treatment. A patient brought in a new prescription for a titrating dose of semaglutide (Ozempic), to be filled at a later date (i.e., the prescription was to be placed on hold for the time being). Only the first part of the titration regimen was entered into the pharmacy system because pharmacy staff did not recognize that the titration would involve multiple steps and dispensing different strengths of the product. This error was identified and corrected before the medication was dispensed to the patient.

The pharmacy recognized the opportunity that this near-miss event provided to improve the processes related to dose titration steps, with the aim of preventing a similar error that could go on to cause harm.

Strategies to Support Near-miss Event Reporting

By reporting and analyzing near-miss events, important learning can be achieved to support continuous quality improvement. Consider the following strategies in planning your pharmacy’s approach to reporting near misses.

1. Establish a near-miss event protocol. Consider the following criteria when deciding whether to report a near miss:
   • Impact – would this event result in harm if it reached the patient?
   • Recurrence – does this event happen repeatedly?
   • Learning – could learning from this near-miss event benefit colleagues and patients in other pharmacies?
2. Use a template for quick documentation. A template will help you capture essential details, especially when the pharmacy is busy. Consider using the CPhM near-miss report form to quickly document near-miss event details to be entered into your reporting platform at a less busy time.
3. Engage the team. Encourage pharmacy team members to communicate near-miss events when they happen. This helps to create a just culture where the team feels comfortable reporting errors, without fear of blame or shame for these mistakes.
   

Reports of medication incidents and near-miss events submitted to the National Incident Data Repository for Community Pharmacies undergo further analysis to identify strategies that will prevent patient harm, and develop resources such as the National Snapshot for shared learning.