Nursing care
Near miss vs adverse event: classifying safety events and what the nurse does next
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
The difference is whether harm reached the patient. An adverse event is injury caused by medical care rather than the underlying disease. A near miss is an error or hazard that could have caused harm but did not, because it was caught in time or by chance. Both are reported through the incident system so the organisation can fix the underlying cause.
Decide whether the patient was harmed
An adverse event is an injury resulting from care, such as a fall with a fracture, a pressure injury, or bleeding after a wrong-dose anticoagulant. Some adverse events are preventable and follow an error; others, such as a known drug reaction in a patient with no prior history, occur despite appropriate care. Either way, harm happened.
A near miss, sometimes called a close call or good catch, is an event that did not injure the patient only because of luck or a timely intervention. A nurse who notices the wrong medicine during the bedside scan before giving it, or a patient who says, "These aren't my usual pills," are classic examples. An error that reaches the patient but causes no harm is often categorised separately.
Why near misses are reported too
Near misses reveal the same system weaknesses that cause harm, such as look-alike packaging, confusing pump settings or interruptions during medication rounds, without a patient being injured. They happen far more often than adverse events, which gives organisations more data to act on. Not reporting a near miss leaves the hazard in place for the next patient.
Incident reporting systems depend on frontline staff, and nurses are among the most frequent reporters. Effective systems keep reports confidential, take a nonpunitive approach to honest errors and feed back what changed. Incident reports are quality tools, not disciplinary records, and in many organisations they are not filed in or referenced within the patient's chart.
Immediate nursing actions for each
For an adverse event, the first priority is the patient: assess, stabilise and get help. Notify the provider, carry out orders such as monitoring or antidotes, and inform the charge nurse. Document objective facts in the chart: what was observed, the assessment, who was notified and the care given. Then complete the incident report as soon as practical while details are fresh.
For a near miss, secure the hazard, such as removing the wrong medicine and checking the rest of the supply, and complete an incident report describing what happened and how it was intercepted. Because the patient was not affected, a chart entry may not be needed beyond normal care. Disclosure to the patient of adverse events follows organisational policy, often led by the provider.
From report to system change
Reports feed into review processes that look for causes beyond the individual, such as staffing, equipment design, communication gaps or unclear policies. Serious adverse events may trigger a root cause analysis, while patterns of near misses can prompt changes like separating look-alike medicines, adding barcode checks or adjusting pump libraries. Nurses often join these reviews and help test the fixes.
A culture that responds fairly to reports encourages more of them. Honest mistakes and system failures are addressed through learning and redesign, while reckless behaviour is managed differently. For the exam, recognise that the purpose of reporting is improvement, that reports should be factual and free of blame or speculation, and that completing one is a professional responsibility rather than an admission of guilt.
Work through an original scenario
Hypothetical item: a nurse prepares insulin and, during the independent double check, a colleague notes it is the wrong type. Nothing is given. What should the nurse do? Options: say nothing since no harm occurred, document the incident report reference in the progress notes, complete an incident report describing the near miss, or report the colleague for slowing the round.
Completing an incident report is correct; this is a near miss that exposes a risk worth fixing. Saying nothing loses the learning, referencing the report in the chart is a common documentation error, and the colleague acted correctly. If the wrong insulin had been given and the patient became hypoglycaemic, it would be an adverse event, and treating the patient would come first.
Sources and further reading
AHRQ PSNet: Adverse events, near misses, and errors. Definitions of adverse event, preventable adverse event, near miss and error, with a medication near-miss example.
AHRQ PSNet: Reporting patient safety events. Purpose of reporting errors and near misses, nurses as frequent reporters, confidential nonpunitive systems and the need for feedback and action.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our safe and effective care practice questions are the closest set to what this page covers.
One question from the safe and effective care set
A nurse on a medical unit receives report on four clients. Which client should the nurse assess first?
Rationale
Prioritization items are airway, breathing, circulation, in that order — the ranking survives every rewording. Audible gurgling around a fresh tracheostomy is a partially obstructed airway and it is the only option that can kill the client in the next few minutes. Fever, post-op pain, and a glucose of 232 are all real problems that need the nurse, just not first.
Answer: C
Common questions
Is an error that reaches the patient without harm a near miss?
Classification systems vary. Many define a near miss as an error caught before reaching the patient and categorise a reached-but-harmless error separately. Both are reported.
Should the incident report be mentioned in the patient's chart?
Commonly no. Chart the clinical facts, assessment and actions. Follow local policy, which usually keeps the incident report as a separate quality document.
Will reporting a near miss get the nurse in trouble?
Effective reporting systems are confidential and focus on fixing systems rather than blaming individuals for honest mistakes. Reckless or intentional misconduct is handled differently.
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