Good Catch! Encouraging a ‘no blame’ reporting culture for near misses in our dispensing areas

John Minshull, Deputy Director, London Medicines Information Service, Specialist Pharmacy ServiceExample from North Tees and Hartlepool NHS Foundation TrustPublished
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Summary of the example

  • The Trust has 2 main inpatient dispensaries located on different sites.
  • In August 2017 a paper-based, “near miss” reporting system (termed ‘good catches’ locally to reduce stigma around reporting) was introduced across both sites.
  • RPS guidance was used to code near misses.
  • Initial reporting was welcomed on both sites.
  • There were initially reservations about what data was being used for. Some staff were concerned that reporting would result in disciplinary/negative consequences. Explanations of the organisational benefits of an open-reporting culture resolved this.
  • In May 2018 an analysis of the first 100 near misses reported on one site was conducted. This was valuable, and enabled a number of small, meaningful changes to be made to prevent certain prevalent events from reoccurring.
  • Users requested to utilise technology to record near miss data.
  • An electronic ‘good catch’ log was set up across both sites in January 2019. This log was easily accessible to pharmacy staff across both inpatient dispensaries, aseptics suite, outpatient pharmacy and ward based dispensing services.
  • Over 200 entries have been made in this log within 3 months of it going live.

Why we think it’s important

  • Colleagues value the importance of learning from mistakes. The negative perception of near miss recording has been challenged successfully.
  • Staff have been empowered to take control of near miss reporting in their areas in order to improve the services that they provide to patients.
  • People find an electronic system of recording near misses to be efficient and easy to use.
  • This example has provided us with a working example of how simple changes can make a difference to the way that we can encourage safety culture in our organisation

Learn more about the example

Aims and objectives of the work

  • To implement a paper-based system for recording errors.
  • To use this system to identify themes and trends in terms of errors that may be prevented.
  • To analyse the effectiveness of such an intervention.
  • To utilise technology to make the process of near miss reporting more accessible in ‘other’ areas where dispensing occurs (bedside/outpatients/aseptics).
  • To create a system of reflection that colleagues can use to support their own learning and development when incidents/near misses occur.


  • Initial paper-based system implemented, ‘coded’ using standard RPS coding for near miss reporting in dispensaries.
  • System shared in department and use by all pharmacy teams encouraged.
  • Rationale behind use (open reporting/fair blame culture) explained to team.
  • Trialled for one year, tested for effectiveness.
  • Developed further as an electronic system, accessible by wider team.
  • Stakeholder engagement in relation to rationale for electronic recording and content of the electronic form.
  • Promoted electronic system of reporting at weekly huddles in department and by email.

Key findings

  • A paper-based near miss log was an effective way to recognise trends and patterns in dispensing errors that did not leave our inpatient dispensaries.
  • The log enabled us to implement small changes to prevent these errors from reoccurring.
  • Feedback from stakeholders around developing the near miss recording system further included the prospect of developing an electronic solution that could be accessed by the whole pharmacy team regardless of location.
  • Following stakeholder engagement, this was designed and implemented, and together with a small amount of promotion around the rationale for recording near miss data, has resulted in good uptake throughout the department.
  • Over 200 entries have been made within 3 months of the electronic system going live.