# Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush. The same week, a nurse gives 1 g of intravenous cefazolin, ordered for a roommate, to a 72-year-old man. He has no drug allergy. He is monitored for 24 hours, and his vital signs, skin, and kidney function show no change. How should the potassium chloride event and the cefazolin event be classified?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629756  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush.

The same week, a nurse gives 1 g of intravenous cefazolin, ordered for a roommate, to a 72-year-old man. He has no drug allergy. He is monitored for 24 hours, and his vital signs, skin, and kidney function show no change. How should the potassium chloride event and the cefazolin event be classified?

## 보기

1. Potassium: no-harm incident; cefazolin: near miss
2. Potassium: near miss; cefazolin: adverse event
3. Potassium: near miss; cefazolin: near miss
4. Potassium: near miss; cefazolin: no-harm incident **✔ 정답**

**정답: 4**

## 해설

A near miss is an error that does not reach the client; the potassium chloride vial was stopped by the scan before any drug was drawn up. A no-harm incident reaches the client but causes no detectable harm; the cefazolin was given to the wrong client, but monitoring showed no harm. An adverse event requires harm caused by care, so neither event qualifies, and extra monitoring alone does not turn a no-harm incident into an adverse event.

## 심화 해설

Classification of medication safety events

The two events sit at different points on the patient safety continuum, and the key distinction is whether the error actually reached the patient.

Near miss describes an error that is intercepted before it reaches the client. In the potassium chloride event, the nurse picked up the wrong vial, but the barcode scanner rejected it before any drug was drawn up or administered. The error was caught at the point of preparation, so the patient was never exposed to the concentrated potassium. This fits the definition of a near miss precisely: the unsafe act occurred, but no drug reached the patient. The World Health Organization framework used in near-miss reporting studies applies the same logic—an event qualifies as a near miss only when the error is stopped before it touches the patient [1].

No-harm incident is a different category. Here, the error does reach the client, but no detectable harm results. The cefazolin case illustrates this: the antibiotic was ordered for a roommate but was actually administered to the 72-year-old man. The drug entered his bloodstream, so the error reached the patient. However, monitoring over 24 hours showed no change in vital signs, skin, or kidney function, and he had no drug allergy. Reaching the patient without causing harm is what separates a no-harm incident from a near miss.

An adverse event requires actual harm caused by the care delivered. Neither event meets this threshold. The potassium chloride never reached the patient, and the cefazolin produced no detectable physiological change. Key point! Extra monitoring or observation does not convert a no-harm incident into an adverse event—harm must actually occur, not merely be watched for.

| Category | Reached patient? | Harm occurred? | Potassium chloride event | Cefazolin event |
| --- | --- | --- | --- | --- |
| Near miss | No | No | Yes (scanner stopped it before preparation) | No |
| No-harm incident | Yes | No | No | Yes (wrong patient received drug, no harm) |
| Adverse event | Yes | Yes | No | No |

The conceptual distinction matters for reporting systems. Near-miss reporting frameworks are designed to capture errors before patient contact because these events reveal latent system weaknesses without the burden of patient harm . A barcode scanner that rejects a wrong vial is functioning exactly as intended—it is a safety barrier that converted a potential medication error into a near miss. In contrast, the cefazolin event bypassed all barriers and reached the wrong patient, but the absence of clinical consequences places it in the no-harm category.

Watch out! Do not classify an event as an adverse event simply because monitoring was performed. Monitoring is a response to the error, not evidence of harm. The classification depends on what actually happened to the patient, not on what could have happened or what was done afterward. The concentrated potassium chloride could have been fatal if administered, but because it never reached the patient, it remains a near miss—the potential severity does not change the category [1].References (research sources)

- [1]Exploring the Accuracy of Near-Miss Reporting: A Mixed-Methods Study.Research articleAlfayez A, Aljabri D, Althumairi A, Alfaraj E, Alkwaiti A, Alanzi T (2026) · DOI: 10.1097/PTS.0000000000001463

## 임상 시나리오

Medication Safety Event ClassificationNear miss vs. no-harm incident vs. adverse event
The critical question is whether the error reached the patient. A near miss is intercepted before administration—like the potassium vial rejected by barcode scanning before any drug was drawn up.

A no-harm incident reaches the patient but causes no detectable harm—like cefazolin given to the wrong patient with 24-hour monitoring showing no changes in vital signs, skin, or kidney function.

CautionExtra monitoring alone does not convert a no-harm incident into an adverse event. An adverse event requires actual harm caused by care, not just the potential for harm.

## 핵심 개념

- **Near miss** — An error that is intercepted before it reaches the patient; no drug is administered.
- **No-harm incident** — An error that reaches the patient but causes no detectable harm.
- **Adverse event** — An event that causes actual harm to the patient as a result of care delivered.
- **Barcode scanning** — A safety technology that verifies medication identity before preparation or administration.
- **Medication safety continuum** — A framework classifying errors from near miss to no-harm incident to adverse event based on patient exposure and harm.

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