Patient Safety & Quality AssuranceQuestion 78 of 100
A technician pulls the wrong strength of a medication but notices the mistake and corrects it before the pharmacist's final check, so the patient is never affected. Under a just-culture approach, what should happen next?
a.Nothing, because no patient was harmed
b.The technician should receive formal discipline for the mistake
c.It should be reported only if the same technician repeats the mistake
d.The near miss should be documented and reported internally so the underlying system weakness can be analyzed and corrected
Explanation
Near misses are free lessons: reporting one lets the pharmacy run a root cause analysis and fix the shelf layout, label design or workflow that made the error possible before a patient is harmed. A just culture separates honest system-driven error from reckless behavior, so punishing the report or waiting for a repeat simply teaches staff to stay silent and leaves the hazard in place.
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