Learning from Near Misses Is an Important Part of Medication Safety

Supporting continuous quality improvement (CQI) and reducing the risk of patient harm from medication incidents in, or involving, Ontario pharmacies is at the heart of the Assurance and Improvement in Medication Safety (AIMS) Program. By identifying how medication incidents could occur in their own pharmacy, pharmacy professionals can implement quality improvement strategies that strengthen processes and reduce the likelihood of similar incidents in the future.  

One aspect of AIMS that is often overlooked is the importance of reporting near misses. These are events that could have led to inappropriate medication use or patient harm but were intercepted before reaching the patient.  

Near misses provide valuable learning opportunities. Analyzing these events to identify contributing factors can help pharmacies strengthen safeguards and make improvements that prevent future incidents.  

When Should You Report a Near Miss? 

Use your professional judgment. Ask yourself: 

Could this have been prevented?
If the near miss highlights an opportunity to improve an existing pharmacy process or procedure, it should be reported. 

Is this a recurring issue? 
If more than one near miss occurs under similar circumstances, it should be considered recurring and reported. Recurring events may indicate gaps in processes or procedures and signal the need for improvement. 

What is the implication to patient safety? 
Consider the potential impact if the medication had reached the patient. For example, does the event involve vulnerable patient populations or high-risk medications? What could be the impact on your patients if no action is taken and the event occurs again? 

 All reported incidents and near misses should be reviewed and discussed during the pharmacy’s regular CQI meetings.  

It’s important to remember that reporting near misses and incidents is only one pillar of the AIMS Program. Pharmacies and pharmacy professionals are also expected to document details of the events, analyze them to identify contributing factors, develop and implement CQI plans to minimize recurrence and share key learnings with all staff to support ongoing quality improvement. 

Why Is Reporting Near Misses Important? 

The value of reporting near misses is not unique to pharmacy. Other sectors including aviation, railways, construction, and utility companies also analyze near misses to identify underlying flaws in processes or procedures. 

Reporting and analyzing near misses can: 

In pharmacies, reporting medication events, including near misses, is important because it enhances patient safety and promotes a culture of safety and continuous quality improvement. Medication incidents are preventable, and active participation in the program helps pharmacies identify system gaps and implement targeted improvements to reduce the likelihood of recurrence.  

How Is Incident and Near Miss Reporting Changing in the AIMS Program? 

Pharmacy professionals must continue to anonymously report all medication incidents and near misses. 

In 2026, reporting may be completed through the pharmacy’s incident management platform (if available), or by using an alternative format as directed by the Designated Manager. This template provided by the College may also be used.

As of January 1, 2027, incidents and near misses must be reported into the pharmacy’s incident management platform and data must be contributed to the National Incident Data Repository for Community Pharmacies (NIDR). 

Throughout 2026, pharmacy professionals and pharmacies must continue to meet the requirements of the AIMS Program and the supplemental Standard of Practice. For more information, please see the Pharmacy Connection article AIMS Program: Expectations and Requirements of Pharmacies During 2026.