The near miss nobody logged

Introduction

A near miss is an error that is caught before it reaches the patient. Catching it is good. Not recording it is a missed chance for the whole team to learn. This scenario looks at why people stay quiet about near misses and what changes when they do not.

What happened?

A dispensing assistant was bagging up prescriptions on a busy afternoon. As she put the label on a bag she noticed that the box inside was a 40 mg strength and the label said 20 mg. The item had been checked and passed by the pharmacist an hour earlier.

She swapped the box for the right strength, re-checked it against the label, and bagged it. She did not tell the pharmacist and did not write it in the near miss log. She thought it would look as if she was pointing the finger at the pharmacist, and the log always seemed to be about blame.

Three weeks later the same two strengths were mixed up again. This time the wrong one went home with a patient, who noticed the difference and rang the pharmacy. Nobody was harmed. When the team looked into it, the assistant mentioned the earlier near miss. The two strengths had been sitting next to each other on the shelf since a stock reorganisation.

What was the concern?

• A pattern was missed. The first event was a warning that the shelf layout was unsafe. Because it was not recorded, nobody saw it.
• The assistant corrected an item after the pharmacist's check without telling the pharmacist. Any change after the final check needs the checker to know.
• The team's culture made recording feel like blame, so the log did not do its job.

What was the outcome?

In this scenario the pharmacy recorded the dispensing error, told the patient what had happened and why, and reviewed both events together. The two strengths were separated on the shelf with a warning shelf-edge label. The team agreed a new rule: every near miss goes in the log the same day, with no names needed, and the log is reviewed together once a month to look for patterns. The assistant was thanked for speaking up when she did.

What can we learn?

1. A near miss is information. Recording it is how the team finds the problem behind it.
2. If you correct an item after it has been checked, tell the checker. They need to know their check missed something.
3. A good near miss log records what happened and why, not who. If your log feels like a blame list, say so.
4. Look for patterns: the same product, the same shelf, the same time of day, the same task.
5. Small fixes prevent big errors. Separating two packs on a shelf takes a minute.

Relevant pharmacy practice

The GPhC expects pharmacies to record, review and learn from dispensing errors and near misses, and to share that learning across the team. Its learning from incidents toolkit describes a just culture, where the focus is on why an error happened rather than who made it. Recording near misses is one of the things inspectors look for.

PPets learning connection

Error reporting and learning from incidents are part of the Level 2 Certificate. This scenario works well as a five minute team discussion at a huddle.

Record this as CPD

Registered pharmacy technicians can use this article towards GPhC revalidation, as an unplanned CPD entry or as the starting point for a reflective account. Pharmacy assistants and trainees can use it as evidence of reflective practice. Note down three things:

1. What you learned from this article
2. How you have applied it, or will apply it, in your own role
3. The benefit to the people who use your pharmacy's services

Sources and further reading

• GPhC pharmacy team toolkit: learning from incidents
• GPhC standards and guidance for pharmacy professionals

Related from PPets

• Level 2 Certificate for pharmacy support staff
• Free resources

This article is for general educational purposes only. It is not legal advice, professional regulatory advice or clinical advice about an individual patient. Always follow your pharmacy's SOPs and check current official guidance and product information.

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