Near Miss Nursing

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A near miss is a situation where an incident almost happened, but was noticed before any harm was done to the patient. A near miss I once encountered was when I was emergencyly pulling an atropine for my patient whose heart rate was steadily dropping. During this time I overrode the medication, as we typically do in emergencies, and pulled a black wrapped syringe with a purple label on it, from the atropine pyxis pocket. As I was rushing back down the hall to my patients room to administer this medication, I happened to look down at the drug. It was then I realized not only was it not atropine, but it was Labatolol in a syringe within a similar black wrapper with a purple label that had been loaded into the atropine pocket. Administration of this …show more content…
Because of our patient safety culture, I had the confidence to discuss this with not only my manager, but the critical care pharmacist as well. A study completed by Vikan et al. (2023), showed that a more positive patient safety culture is associated with fewer adverse events in hospitals. Pharmacy was called after the event, and an incident report was written about the issue. After that, we no longer use syringe labatolol for our patients. A near-miss event can happen to anyone and they need to be addressed as quickly as possible in order to prevent future incidents. Medical errors are found to be the third highest cause of death after cancer and heart disease (Toren et al., 2021). By reporting near misses, we can help improve patient safety, and prevent future accidents from occurring in the future. References: Toren, O., Dokhi, M., Dekeyser, F. (2021). Hospital nurses’ intention to report near misses, patient safety culture, and professional seniority. International Journal of Quality in Health Care, 33. https://doi.org/10.1093/intqhc/mzab031 Vikan, M., Haugen, A., Bjornnes, A., Valeberg, B., Deilkas, E., Danielsen, S.