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Benefits of Reporting and Analyzing Nursing Students' Near-Miss Medication Incidents

Dennison, Susan MSN, RN, CPPS; Freeman, Michelle PhD, RN, CPPS; Giannotti, Natalie PhD, RN; Ravi, Padma MN, RN, CPPS

Author Information
doi: 10.1097/NNE.0000000000001164


Medication errors and near-miss incidents are known to occur frequently in all health care settings. This reality supports the major focus that prelicensure nursing programs place on competencies in safe medication administration. A related competency, often overlooked, is the knowledge and skill required to report medication errors and near-miss incidents.1–3

A variety of different causes have been identified for medication errors and near-miss incidents, but an accurate number of these incidents remains elusive. A major factor contributing to this knowledge gap is the lack of reporting of both types of incidents by all health care professionals. Underreporting by nurses who are responsible for administering the majority of medications has been attributed to a fear of reporting and the perception that mistakes would be held against them.4 Additional factors include confusion over the definition of a reportable medication incident and onerous reporting processes.5,6 Nurses in a Canadian study perceived that more than 40% of errors that occurred on their unit were not reported.5

From our experience, another gap is the lack of knowledge of how to report and the scarcity of educational resources to guide effective reporting. Underreporting combined with ineffective reports contributes to a lack of understanding of the actual number and frequency of these incidents and the complex contributing factors. This has hindered the design of safer medication management systems to mitigate these factors. It has also failed to fully capture and illustrate the challenges nurses face when attempting to administer medications safely.

Underreporting of nursing students' medication incidents has also been identified. Disch and colleagues3(p26) found that there were relatively few studies investigating nursing students' errors and near misses, with most focused on medication errors. They surveyed nursing schools in the United States to explore whether they had a policy for reporting and following-up of students' errors and near misses, a tool for reporting errors and near misses, a process for identifying trends, and strategies for follow-up. They found that 55% of the 494 schools responding did not have a reporting tool, 48% did not distinguish between errors and near misses, and 81% did not have a process for tracking error trends. Only 31% had a written policy and process for follow-up with students.

Asensi-Vicente and colleagues7 conducted a systematic review of 19 studies of medication errors involving nursing students published between 2005 and 2017. Their findings support high rates of errors by nursing students, underreporting of these errors, and wide differences in the way findings were reported. Barriers to reporting included fear and a tendency for the program to focus on the individual student rather than system factors that contributed to the error.

Teal and colleagues8 conducted a retrospective survey of nursing students' self-reported error and near misses that occurred in their clinical settings and simulation laboratories. They cautioned that nursing students might learn to accept underreporting by learning “error hiding” from nurses in the clinical setting and recommended that information on student errors be integrated in theory, simulation experiences, and clinical practice. They suggested that providing students with the opportunity to complete a medication incident report would teach them about system issues that can result in errors and near misses. In addition, they recommended that studies on contributing factors and the impact of education and safety strategies on incident rates were neded.


Over the past 12 years, our school of nursing has designed and tested an online incident reporting system to address this gap and support the achievement of competency in reporting. This quality improvement (QI) project has used ongoing plan-do-study-act cycles to improve the efficiency and effectiveness of the information reported. The current form is easily accessible by a web link and collects pertinent demographic information (ie, student name, year in program, time and location of incident, and medication(s) involved). Three types of medication incidents are reported: errors, near misses, and discovered errors. Simple definitions were chosen to encourage reporting. A medication error is defined as an error that reached the patient. A near miss was an error that occurred during the medication administration process but did not reach the patient. A discovered error was an error made by other members of the health care team but discovered by the nursing student and clinical instructor.

Data analysis was completed at the end of each school year and revisions were made in the form to improve both the efficiency of reporting and the usefulness of the data. Three sections required the most attention. These included types of incidents, contributing factors, and recommendations. The types of incidents were revised to offer more options. For example, incorrect dose was divided into the types of incorrect doses that can occur (ie, dose too little, dose too much).

To improve reporting of contributing factors, a review of the literature was conducted to determine how these could be better organized to inform education and practice. Research conducted by the Institute for Safe Medication Practices identified 10 system elements that influenced medication safety with errors directly traced to weakness or failures in these elements.9(p56) These system elements were adapted to better reflect the roles and responsibilities of nurses and nursing schools in the medication administration process.10 For example, medication delivery device acquisition, use, and monitoring were reworded to state drug delivery device since nursing schools do not play a role in device acquisition in their clinical placement sites. Definitions of the 10 factors can be found in Supplemental Digital Content Table 1 (available at:

Each of the 10 factors is presented to the student with a yes or no option. If the factor contributed to the incident, additional options are presented to better explain the contributor(s). For example, if patient factors contributed to the event, the student identifies all the patient information that was not available and/or not accessed. The contributing factors and options can be found in Supplemental Digital Content Table 2 (available at: The 10-factor framework has allowed us to better categorize, organize, and analyze the wide array of contributing factors that are known to contribute to medication incidents.

The Recommendations section, which encourages reflection on the incident and reinforcement of safe medication practices, was reworded to link more closely with the 10 contributing factors. The student is asked how to prevent this incident from happening again. The Recommendations section from the incident reporting form can be found in Supplemental Digital Content Table 3 (available at:

Our policies were summarized into job aids referred to as standard operating procedures (SOPs). The SOPs outline the expected steps in the medication administration process and the role of the student and the clinical instructor in the process (see Supplemental Digital Content Table 4, available at: In years 1, 2 and 3, students are supervised at every step of the process by the clinical instructor, and only 2 to 4 students give medications on a clinical day. The expectations for students not administering medications are also outlined in the SOPs and they prepare as if they will be giving medications. The precepted student (year 4) is supervised by the preceptor until deemed competent before preparing medications independently.

Although we track 3 types of medication incidents, the purpose of this article is to focus on our near-miss incident reports. This addresses a gap since most of the current literature is focused on nursing student errors.3 Near-miss reporting by nursing students requires an investment of time by the students and clinical instructors who guide them. It also requires faculty time to analyze the information. The usefulness of near-miss reporting by nursing students has not been described in the literature.

Reason11 describes a near miss as “any event that could have had bad consequences but did not” and therefore refers to them as “free lessons.”(pp118-119) They are viewed by safety experts as positive events (good catches) since the error was interrupted and the negative consequences averted. Reason explains that near-miss incidents range from benign events (eg, student chooses wrong medication but corrects error immediately) to potentially catastrophic (eg, student prepares insulin dose 10 times ordered dose). These incidents can be caught (and therefore prevented) by backup systems (eg, independent double checks) and the actions of individuals or the team. He emphasizes that analyzing near-miss events can work like vaccines to mobilize the system to prevent a more serious occurrence in the future.

The aim of this QI project was to analyze near-miss incident reports submitted by nursing students to understand the types of incidents and their contributing factors. We wanted to determine whether our SOPs were successful as a defense in catching the errors before they reached the patient. In addition, we wanted guidance on improvements that could be made in both theory and laboratory/simulation content on medication administration. Lastly, we wanted to know whether our incident reporting system could be improved.


Design, Setting, and Sample

This project was approved by the Research Ethics Board as quality assurance/QI at the home university of the researchers. Constructivist learning theory, requiring the active participation in incident reporting by the student, guided our approach.12 Each student was encouraged to actively engage in identifying and reporting near misses. This demonstrated their knowledge, skill, and attitude about the importance of reporting and how to effectively report, and included their insights on how to prevent this type of incident from happening again.

The project took place in a 4-year baccalaureate nursing program at a university located in southwestern Ontario with approximately 900 nursing students. At the time of this project, students in first year were not administering medications, so the eligible sample was approximately 780 students each year. Education on the incident reporting system and importance of reporting near misses was provided to clinical instructors and students by the program's clinical coordinators in meetings and posted online. Participation in the reporting of a near miss was voluntary but encouraged by the coordinators and clinical instructors. Three years of near-miss incidents were analyzed and examined by incident description, incident type, and contributing factors using the 10-factor framework.


Data were downloaded from an electronic survey and analyzed using SPSS version 2613 and Microsoft Excel. Before data analysis, the data were explored for accuracy of entries and missing data. All identifiers were removed. The number of near-miss reports filed by students in the second, third, and fourth years from 2017 to 2020 was examined. Descriptive statistics of the number of incident types and contributing factors were summarized.

A Pareto chart was created to analyze and display incident types. According to the Pareto principle (80/20 rule), roughly 80% of the effect comes from 20% of the causes.14 This chart arranges incident types in order of frequency (highest to lowest) and identifies the ones occurring in 80% of incidents. These are referred to as the vital few. The remaining types (20% of incidents) are called the useful many. To analyze the contributing factors, a fishbone diagram using the 10-factor framework was created to illustrate the many causes that contributed to near misses and help us to focus on areas that need attention.14

In addition, a qualitative analysis of the reports was conducted to provide insights into the incident, common problems, who and what prevented the error from reaching the patient, and contributing factors. Coding of each near-miss report was done by 2 researchers who summarized relevant details including who was responsible for catching the near miss, contributing factors, and common themes.


A total of 236 near-miss medication incident reports were filed between September 2017 and March 2020 representing 3 school years. The 2020 clinical year ended earlier than usual because of the pandemic that restricted clinical access. Five types of incidents accounted for 81.4% of incidents: dose too little (n = 67, 28.4%), dose too much (n = 39, 16.5%), dose omission (n = 33, 13.9%), wrong time (n = 29, 12%), and wrong drug (n = 25, 10.6%) (Figure). The other types of incidents (eg, incorrect patient, incorrect prescribing, and incorrect administration technique), referred to as the useful many, require attention but the findings do not support them as a priority.

Types of near-miss incidents.

Each near-miss event typically has multiple contributing factors. The findings identified that communication (47.9%), competency and education (44.1%), environmental and human limitations (35.2%), and policies and procedures (29.2%) were contributing factors to most near-miss incidents (see the Supplemental Digital Content Figure, available at:

A qualitative analysis of the data provided insights into the quantitative findings and clarified the opportunities to focus improvements. Examples of common incidents and multiple contributing factors to each near miss can be accessed in Supplemental Digital Content Table 5 (available at: For example, in an incorrect drug near miss, a fourth-year student working with an RN preceptor selected the wrong intravenous fluid bag because it was placed in the wrong location. The nursing student caught the error and reported the array of factors that contributed to this near miss including problems with how the bag was stored, labeling/packaging-look-alikes, inexperience on the part of the student, and environment/human factors of distraction and a heavy workload.


Our findings on near misses are consistent with previous research on types of medication errors and their contributing factors. This reinforces that vulnerabilities still exist at all stages of the administration management process. Keers and his team15 conducted a systematic review of direct observational evidence of medication administration errors. They found that wrong time, omission, and wrong dose were the most common types of errors. Cooper16 reported on 26 medication errors by nursing students over 5 semesters that occurred in clinical and simulation settings. She found that almost half of the errors were related to administration errors (incorrect time, wrong site, and incorrect dose), 15% resulted from system issues (missing orders, wrong time in the medication administration record), and the remaining were attributed to a knowledge deficit.

Keers and colleagues17 conducted a systematic review of 54 quantitative and qualitative studies on medication administration errors in hospitals. They found that errors were the result of problems with communication (eg, prescriptions and documentation), problems with supply and storage of drugs (eg, dispensing errors), high perceived workload, equipment problems, patient factors, staff health status (eg, fatigue) and interruptions and distractions. Reason18 reminds us that by focusing on the vulnerabilities in the medication administration process, there is an opportunity to improve its reliability. In keeping with safety experts, near-miss incidents can be examined as a good catch and as good luck.

In the good catch view, the events are examined through a positive lens by reflecting on the strategies that caught the error and reinforcing their use during medication administration. The 236 near-miss events indicated that our safety strategies (eg, SOPs; independent double checks on high-alert medications) were effective in catching these errors. In spite of a wide array of contributing factors such as communication problems and environmental factors, the student, clinical instructor, and/or patient prevented the error from reaching the patient. There is a need to acknowledge this important contribution. We plan to add this question to our reporting form: What safety strategy resulted in this good catch? This will not only reinforce the reporting culture but help us and the student to understand the effectiveness of these interventions. In addition, these findings can contribute to our understanding about how human actions and organizational processes can lead to error detection and prevention, an identified gap in safety science.18 From a policy and procedure perspective, we have objective data that clinical instructor supervision at each step of the administration process is an effective safeguard in catching errors.

In the good luck view, the events remind us not to be complacent about the hazards in the system and that luck does not hold out forever. Taking a proactive stance, targeted strategies are required to prevent the error that might not be caught and harm a patient. Since over 80% of these incidents involved wrong dose, wrong time/frequency, and wrong drug, we know that these are current vulnerabilities related to the medication administration process with our students; these findings should be disseminated widely11 and how this content is taught should be examined; changes to strengthen the content to reduce these types of incidents (eg, more focus in the laboratory on preparing a correct dose) could be introduced. Future reports may inform us whether these strategies are working. The other 20% of incidents (useful many) still require attention since any of these violations (eg, incorrect patient) could result in harm. Both the good catch view (what worked to stop the error) and the good luck view (a reminder not to become complacent) need to be reinforced.

One challenge in applying study findings on medication incidents is the lack of standardization on how the factors that contributed to the incidents are organized, reported, and analyzed.10 The 10-factor framework is an evidence-based approach for standardizing the reporting of the factors that contribute to medication incidents by nursing students.10 It has been adapted to include the individual and system factors that influence the safety of the medication administration process during clinical placements. The findings quantify 10 distinct factors that are frequently described vaguely or anecdotally in the literature. The data allow individual schools to identify, track, and trend the unique factors in medication administration that are experienced in different clinical environments. For example, although all 10 factors were identified as contributing to the incidents, some were found to be more frequently influencing a safe process. Communication factors were involved in almost half of near-miss incidents; competency/education factors (eg, lack of experience and not following safety policies) contributed to over 40%; environment/human factors contributed to 35%; and violating policies/procedures were 29%. The high incidence of communication failures within the health care team highlights the vulnerabilities that unclear orders, unclear medication administration records, and incomplete documentation and poor handoffs present to the student and instructor. The influence that these factors have on safe medication administration and how to mitigate them should be included across the curriculum. Strategies such as effective team communication (eg, handoffs), limiting distractions and interruptions, and practicing mindfulness during medication administration should be included.19

Nursing schools can employ the plan-do-study-act process and use the findings to inform policy and teaching strategies. Case studies can be developed from the reports and embedded in theory, clinical conferences, laboratory practice, and simulation scenarios. The sharing of real-life incidents submitted by nursing students has increased both students' and clinical instructors' understanding of how errors happen and the reality that an error can be made by anyone. Discussions of near-miss incidents allow the student to understand all the contributing factors and develop an appreciation for how errors can be prevented from reaching the patient.

To sustain this work, it is recommended that findings be reported to committees (eg, curriculum committee and clinical practice committee), and action plans developed based on the findings. The sharing of findings has resulted in a plan to better integrate the practice of incident reporting in clinical courses by including it as a course expectation. This will allow every student the opportunity to submit a report based on a case study or an incident such as a near miss. Sharing of findings with clinical practice site partners is also important. It alerts them to vulnerabilities in their medication management systems, thereby contributing to the creation of safer systems for our students/clinical instructors, patients, and all health care professionals.10

Finally, the importance of teaching nursing students to report near misses must be emphasized. Underreporting of errors and near misses has been a persistent problem in health care. This has resulted in a lack of understanding of all the vulnerabilities in the medication management system and hindered the design of safer, evidence-based processes and systems. By submitting reports, students communicate observations about hazards and demonstrate valuing their role in error prevention.


The first limitation is that the incident reporting system has only been implemented and tested in one nursing program. Also, students do not administer medications during every clinical experience and therefore would not have the opportunity to experience a near miss. It is also likely that all near-miss incidents experienced by nursing students were not reported. The submitted reports may reflect a subgroup of instructors and students who felt safe to report and might produce different results if all near misses were reported. Reason11 reminds us that the advantages of learning from this information, even if not perfect, far outweigh the disadvantages.


This project has addressed a gap in the literature on near-miss reporting by nursing students. It supports what safety experts have taught us about the importance of reporting and analyzing near-miss incidents. The findings have provided guidance on how to improve the medication administration content in our courses, the potential hazards in clinical placements, how small failures in a complex medication delivery system can line up to create errors, and whether our policies are effective in catching these failures.

Medication errors continue to harm patients and waste health care resources. Nursing voices in near-miss incident reports will emphasize the value of nursing in improving the safety of the process and contribute to addressing this serious problem. It is essential that nursing schools develop a reporting culture and actively support a just and learning culture to prepare the next generation of nurses to assume a much-needed leadership role in medication incident reporting.


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incident reporting; medication errors; medication safety; nursing students; policies

Supplemental Digital Content

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