Near Miss Errors

Quick reference guide 

This guidance is for superintendents, pharmacy owners, pharmacists and pharmacy staff.

This guidance does not cover dealing with errors that have reached a patient that may or may not have caused harm to a patient. It does not replace any standard operating procedures you may have in place for dealing with errors.

Mistakes do happen

Our near miss error log and near miss error improvement tool, along with supporting guidance, can help you and your pharmacy team to work through the near miss errors (NMEs) and learn from them.

Regular review of NMEs and action taken can prevent similar mistakes from happening in the future. We have produced this guidance to help support clinical governance in pharmacy, and to promote an open culture of recording of NMEs so that all pharmacy staff can reflect and learn from them.

Your pharmacy may already have a procedure for recording NMEs that works for your pharmacy. If not, you can use this guidance to develop, improve or implement one.  

Reporting tool

The Near Miss Error Log (NMEL) can be used to record the near miss errors. By filling in the log, you can collect sufficient information to help capture/visualise the pharmacy environment at the time of the near miss error. For more details on how to use the tool, see our top tips for using a near miss error log.

Improvement tool

This reflection tool can be used to analyse and review the information reported in the near miss error log. Staff can identify trends in near miss errors, discuss possible causes/contributing factors and develop an action plan to help prevent similar future near miss errors. This action plan can be reviewed at a later date to review if successful. For more details on how to use the tool, see our top tips for using a near miss error improvement tool.

How to use the tools

Where to go for further information

external resources

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