Near Miss Management

Near misses provide valuable learning opportunities without the harm associated with actual incidents. After the transition period ends on June 1, 2026, pharmacy professionals must handle near misses according to the established policies and procedures of the pharmacy, including:

• Evaluation: Pharmacy staff must review the pharmacy’s policies and procedures to determine criteria for whether a near miss must be reported to a national database.  The criteria for reporting to a national database must include the following:
  • If the event had reached the patient, it is likely that actual harm would have been caused
  • The event has been a recurring problem for the pharmacy
  • The event provides a learning opportunity for the pharmacy specifically or for pharmacy practice in general
• Reporting: When criteria are met, a report of the near miss must be submitted to a national database using the pharmacy's reporting platform.
• Root cause analysis: For significant near misses, pharmacy professionals should identify root causes and contributing factors to understand why the near miss occurred. This analysis focuses on systemic issues rather than individual blame, helping to identify opportunities for improvement.
• Improvement implementation: Based on the analysis, pharmacies must create and implement action plans to prevent similar near misses from occurring in the future, monitor the effectiveness of implemented changes, and make adjustments as needed. This proactive approach helps prevent potential incidents before they reach patients.