Medication Error Reporting and Prevention

Importance of Near Miss Reporting

Medication errors that did not reach the patient, referred to as "near misses" or "potential adverse drug events," should be reported as errors to prevent future harm and improve system safety 1, 2, 3, 4
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, 2, 3, 4
The British Journal of Pharmacology recommends that 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, 2, 3, 4

Research demonstrates that approximately one-fifth of identified medication errors are near misses that were caught before reaching the patient, with a study finding 20% of 616 medication errors identified were near misses 5
All errors should be reported, regardless of whether they reached the patient, to allow identification of underlying system failures 1, 2, 3, 4

Prevention is ideal, but detection of errors that have occurred is also necessary to identify common errors, their sources, and implement preventive measures 1, 2, 3, 4
The goal of error reporting is to strengthen safety systems before actual patient harm occurs, and analyzing near misses provides opportunities for this 5