This Statement is FALSE
Medication errors that did not reach the patient CAN and SHOULD be reported as errors. These are commonly referred to as "near misses" or "potential adverse drug events," and their reporting is essential for preventing future harm and improving system safety 1.
Why Near Misses Must Be Reported
Detection of errors that have occurred is necessary to identify those that are common in the particular setting, to identify their sources, and to prevent them from happening again 1. The fundamental principle is that system failures resulting in minor errors or near misses can later lead to serious errors that do reach patients 2.
The Evidence Supporting Near Miss Reporting
Spontaneous reporting schemes such as the National Reporting and Learning System in the UK and the Medication Errors Reporting Program in the USA explicitly collect reports of medication errors regardless of whether they reached the patient 1.
Research demonstrates that approximately one-fifth of identified medication errors are near misses that were caught before reaching the patient 1. In one study, among 616 medication errors identified, 20% were near misses 1.
Web-based error reporting systems have been successfully implemented to capture all medication errors, including those intercepted before patient administration, with strong indications that such comprehensive reporting improves patient safety 3.
The Culture of Safety Requires Non-Punitive Reporting
Reporting of errors should be encouraged by creating a blame-free, non-punitive environment 2. This culture of safety emphasizes improving systems rather than blaming individual people 1.
Key Principles for Error Reporting:
All errors should be reported, regardless of whether they reached the patient, to allow identification of underlying system failures 1.
Anonymous and voluntary reporting systems increase the likelihood that healthcare professionals will report near misses without fear of punitive consequences 4.
The goal is prevention: analyzing near misses provides opportunities to strengthen safety systems before actual patient harm occurs 2.
Common Pitfall to Avoid
The most dangerous misconception is believing that only errors causing patient harm warrant reporting. This mindset prevents healthcare systems from learning about vulnerabilities in medication processes that could lead to serious harm in the future 1. Prevention is ideal, but detection of errors that have occurred is also necessary to identify common errors, their sources, and implement preventive measures 1.