A 54-year-old woman is evaluated in the emergency department for severe headache, photophobia, and nausea. She has a past medical history of poorly controlled asthma. The emergency physician evaluates the patient and decides to prescribe a nonselective beta-blocker for a suspected migraine abortive therapy. Before the medication is dispensed or administered, the clinical pharmacist alerts the physician that the medication is strongly contraindicated due to the patient's asthma history. The physician immediately cancels the order and prescribes a different, safe alternative agent. The patient experiences no harm and her headache improves. Which of the following best classifies this incident?
- ASentinel event
- BPreventable adverse event
- Near missAnswer
- DUnpreventable adverse event
- ELatent error
Answer
Near miss
The correct classification is a near miss (also known as a close call). In patient safety taxonomy, a near miss occurs when an error is made but is caught and corrected before it reaches the patient, thereby resulting in no harm. In this vignette, the physician made an active error by prescribing a contraindicated beta-blocker to an asthmatic patient. However, the clinical pharmacist's intervention acted as a successful system defense. Because the drug was never administered, the patient suffered no adverse consequences, fulfilling the exact criteria for a near miss.
Step-by-Step Solution
Key Concept
A near miss (close call) is defined as a medical error that had the potential to cause harm but was intercepted before it reached the patient.