Epidemiologic Burden of Medication Errors that do not Reach Patients

Abstract

The term “near miss,” often employed in discussions about medication errors that do not reach patients, embraces ambiguity. It refers variously to an error that was detected and recovered prior to administration; to an error that could have affected a patient, irrespective of whether it was intercepted; to a process overwhelmingly devoid of direct individual consequence; or—a rare distinction—to checks of a patient’s record owing to uncertainty perceived by the deliverer. Such variability obstructs consensus upon metrics appropriate for summarizing the phenomenon the term is meant to signify. Towards protecting the intended referent from co-optation by inapposite observations, the present effort persists in framing the consideration as near-miss errors, thereby accompanying the term “near miss” with a qualifying modifier. Progress ultimately fashions a precise shared definition suited for formal definition in future usage.

Frameworks for modeling and describing the myriad complexities surrounding the phenomenon of near-miss errors present significant appeal. By organizing error-generating work processes temporally and conceptually, such frameworks rigorously delineate distinctions among stages of operation and clarify distinctions among contributing factors. Elements of these frameworks offer direct support to a generic definition appropriate for research settings. The framework selected for further articulation, originally proposed for the independent analysis of error-generating processes affecting diagnostics and treatment, retains usefulness within the present consideration. Processes contributing to near misses abide by the generic classification containing the four categories of prescribing, transcribing, dispensing, and administering.