Wrong-Patient Medication Near-Miss Reporting

A wrong-patient medication near miss occurs when a medication intended for one client is selected, prepared, or brought to another client but the error is intercepted before administration. The intercepted dose may cause no injury, but the identity barrier has failed; the next attempt may not be intercepted. Under Ontario and British Columbia guidance, a wrong-patient near miss is a serious risk of harm and remains reportable even when no injury or adverse outcome occurred.[1][2] The useful clinical sequence is: stop the medication process, establish whether any exposure occurred, protect and assess the client if exposure is possible, then notify the employer and complete the provincial reporting process. Identity verification is active: use two approved identifiers and match the client with the medication record, order, label, and barcode process when available. A room number, bed, appearance, or familiar face is not enough.[3]