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.