Table 3

Types, definitions, examples and prevalence of near misses

Error typeDefinitionExamplePer cent (no)
OmissionError in which something was not done that should have been done‘We received PT orders for [patient]. Patient noted to be in special respiratory isolation with respiratory symptoms. Noted mention of COVID testing but no test ordered. Is there a concern for COVID with this patient?55 (21)
CommissionError in which something was done that should not have been done‘On pt [name] who was dc'd yesterday—your norco script was for 10/300. Needs to be 10/325. Can you resend to her pharmacy or call them?”61 (23)
DelayError that caused a delay in patient care‘I had transfer orders since yesterday stating no tele (see orders in cerner). Not sure why she stayed in pcu overnight.’37 (14)
CommunicationError related to miscommunication, missed messages or misunderstandings‘Is your team primary on pt now or is ortho? Pt does not have an admission status order on his chart and I've noticed that trauma signed off. Not sure who to contact now for an order before she’s discharged. Thanks.’21 (8)