Near Miss Error Log

Week/Month..................................
Potential
Dispensed Checked Type Possible causes Things to consider adverse event
Time of Name and brand Action
No: Date Staffing level by by of near (see table 1 in (see table 1 in discussion
day of drug taken
(optional) (optional) miss* QRG) QRG) (tick on
completion)
1.

2.

3.

4.

5.

6.

7.

8.

* Type of near miss (see also Table 1) Time of day (examples) Staffing level (record number of staff)
D = Wrong product N = Wrong patient
E.g.
E = Out of date name M = Morning
Number of pharmacists =NxP
product P = Misread L = Lunch
Number of pre-registration pharmacists = N x PR
F = Wrong form prescription A = Afternoon
Number of technicians = N xT
L = Wrong label Q = Wrong quantity E = Evening
Number of dispensers =NxD
M = Missing product S = Wrong strength
Number of healthcare assistants =NxH
MCA = MCA involved

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Table 1: Near Miss Error Codes
Code Type of near Possible causes (non-exhaustive) Things to consider when reviewing (non-exhaustive)
miss
D Wrong product Product put away at wrong location Do the packs look similar? Should you separate?
Product selected incorrectly Who puts away the products? Training issues?
Products mixed on dispensing bench More than one Rx being dispensed at a time?
Misread prescription (Rx) See also misread Rx
Similar packaging Do you dispense from the Rx & not the labels?
Additional product Wrong product ordered or delivered by wholesaler?
Has the wrong product been placed in another bag?
E Out of date Out of date products on shelf Are you checking the expiry dates of medicines regularly?
product Out of date product sent from supplier Does stock rotation occur?
Are you checking the expiry date when you pick the medicine
off the shelf and carry out the final check?
Do the short dated products have a warning/alert sticker on
them?
Are there any more out of date products on the shelf?
Do you check expiry dates of products when receiving them
from the wholesaler?
F Wrong Inadequate prescription detail See also misread Rx
formulation Product selected incorrectly Is everyone familiar with all formulations?
Misread Rx Do the different formulations have similar packaging? Should
they be stored separately?
L Wrong/ Incorrect transfer of information from the Rx Errors likely when label selected from repeats on PMR
transposed/ Misread Rx Are products dispensed and labelled one at a time?
Omitted label Labelling in batches Is the dispensing bench clear of clutter and tidy?
Incorrect label stuck on the wrong product
Products mixed on dispensing bench
M Missing item Products mixed up on dispensing bench Has the missing product been placed in another bag?
Fridge line / CD / Owing Consider use of dispensing basket
Misread Rx Warning label informing of fridge / CD line / owing outstanding
Product not dispensed in a Multi- Dispense and label one product at a time
compartment compliance aid (MCA), Item missed out when preparing for delivery/collection
dispensed separately
Has the product been ordered or out of
stock?
N Wrong patient Incomplete Rx reception process Staff training issues?
name Previous patient selected from PMR Distractions?
Identical patient names Warning for all staff that two patients have the same name
Wrong patient selected from PMR Enough detail on PMR to deal with similar names?
Misread Rx See also misread Rx
Full name not provided on prescription
P Misread pre- Inadequate / ambiguous details Training issue?
scription (Rx) Hand-written prescription Visual impairment?
Poorly performed Rx evaluation process Was professional evaluation performed?
Q Wrong quantity Incorrect transfer of information from Rx Have you selected label from PMR or Rx?
Misread Rx or calculation error Can someone else check your calculation?
Counting error during dispensing If using a counting machine is it regularly calibrated and
checked for accuracy?
Several pack sizes available
S Wrong strength Product put away at wrong location Do the packs look similar? Should you separate?
Product selected incorrectly Who puts away the goods? Training issue?
Products mixed on dispensing bench Are packs placed on shelf with contents identity visible?
Misread Rx Have you read the Rx correctly? Dispense from the Rx not the
label
MCA/ Multi- Product in wrong compartment Is there a SOP in place for dispensing into MCA
MDS compartment Missing/omitted product Is a visual description available for each product
compliance aid/ Product unsuitable for inclusion in MCA Distractions
Monitored Using manufacturers info on drug stability
Dosage System using RPS MCA guidance
UKMI Medicines Compliance Aid Database

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