Treat the near miss as a system signal
Use root-cause and just-culture thinking to frame a pharmacy near miss as a system learning opportunity.
The reframe: the near miss is a map of the system. When a pharmacy catches an error before it reaches the patient, the team has two choices. It can treat the catch as proof that vigilance worked, or it can treat the catch as evidence that the process allowed risk to travel too far. Root Cause Analysis pushes you toward the second choice. It asks what conditions, barriers, information, handoffs, equipment, and norms shaped the event. Separate event, behavior, and condition The event is what happened: wrong strength selected, label attached to the wrong bag, refrigerator alarm ignored, refill promised…
Sign up free — one personalized lesson every day, matched to your role and goals.
Already have an account? Sign in