Medical Near Misses--Where Do They Go?

When two planes nearly collide in mid air, it is newsworthy and we immediately hear about it. But if a medical "near miss" tree falls in the forest of the medical system, can you hear it? In other words, where does it go? Is it reported, acted upon, and corrected so it will never come to fruition and harm a patient?

An example will bring this issue to light. The other day, my wife visited the pharmacy at a "chain" store to pick up a medication for one of our sons. When she returned home, there were four bottles in the bag. One was our son's medication. The other three were a chemotherapy drug, and anti-nausea medication, and another medication I can't even remember. Obviously, we were given some poor cancer patient's chemo drugs. Ugh.

Aghast, my wife called the pharmacy. They apologized and asked her to return the meds, which she did. The pharmacist told her the other three meds "must have fallen in the bag." Yeah, right. So what happened after she returned the meds? Did the pharmacy fill out an incident report and voluntarily report it to the retailer? Was an investigation initiated to get to the root cause of this egregious error and establish or modify existing safety systems to make sure this error did not happen again? Or did the pharmacy simply breathe a sigh of relief that such a colossal screw up didn't result in serious harm to the patient and go about its business like nothing happened (the ostrich approach)?

We'll never know. But it makes me wonder that, if this happens again, and a pateint who is harmed brings a lawsuit, will lawyers for the pharmacy say with a straight face: "this pharmacy has a spotless record and nothing like this has never happened before."

Just so you know, Ohio is one of 18 states that have NO requirement to report "adverse events" or even things like hospital acquired infections. So if ACTUAL adverse events are not even required to be reported, what do you think happens to near misses?

So, it appears that your only remedy is to go over the head of who was responsible for the error and try to report it yourself. Otherwise, you may be standing on the tip of an iceberg and not even know it. And somewhere down the road it may just crash into someone else.

These mistakes will continue to occur unless and until the medical delivery system adopts a zero tolerance policy for errors similar to the airline industry.