Review Question - QID 217613

This scenario, in which a patient almost received the wrong dose of insulin due to a medical error but did not suffer any actual harm, is an example of a near miss event.

A near miss is defined as any error or event that could have resulted in an adverse event occurring to a patient but did not actually result in harm. These potential adverse events that could have caused harm are avoided either by chance or because someone or something intervened between the possible and actual harm. Despite the fact that no actual patient harm occurs in near misses, the underlying errors that almost result in harm are important to understand because the same process could cause real harm later. For example, a nearly-delivered incorrect medication or almost performing a wrong-sided surgery are both examples of events that could cause catastrophic harm if they were not stopped just in time.

Rodziewicz et al. present a review article on the types of medical errors and harm that can occur to patients. They discuss how near misses provide excellent opportunities to develop strategies to avoid actual harm in the future.

Incorrect Answers:
Answer 1: Malpractice describes improper, negligent, or illegal activity by a medical practitioner that results in patient harm. In this case, no harm occurred to the patient, and the error can be attributed to an intervening emergency rather than improper behavior. This does not excuse the mistake but rather suggests that systemic root causes and processes should be investigated.

Answer 3: Negligence describes the failure of a healthcare provider to meet the standard of care provided by an average qualified provider. Specifically, this concept is invoked in contexts where gross deviation from acceptable norms is involved (e.g., showing up drunk to work). In this case, the nurse made a mistake that could easily have occurred to anyone in the healthcare industry. Therefore, it represents a systematic process and root cause problem rather than the negligence of a specific healthcare provider.

Answer 4: Non-preventable adverse events are harms that occur to patients despite adherence to the best available treatment evidence. In this case, no harm occurred to the patient and, if it had, the harm could have been prevented if the error in syringe identification had not occurred.

Answer 5: Preventable adverse events describe harm that occurs to patients as a result of healthcare interventions due to sub-optimal practice. If the insulin had been delivered to the incorrect patient, this would be an example of a preventable adverse event; however, in this case, no harm was actually done.

Bullet Summary:
A near miss is defined as any error or event that could have resulted in an adverse event occurring to a patient but did not actually cause harm.