Background:
Near misses and adverse events in healthcare often result from communication failures, medication errors, and clinical judgment lapses. While not all cause direct harm, they expose weaknesses that can compromise patient safety.

Methods:
A literature review was conducted using PubMed and credible news sources from the past decade. Real-world cases were analyzed to identify recurring issues and practical strategies for prevention.

Results:
Communication failures are a leading cause of near misses. Examples include misheard verbal medication orders and illegible handwriting leading to drug errors. In Hong Kong, a dysphagic patient died after receiving a regular diet due to a misunderstood “diet as tolerated” order, highlighting the need for clear, accurate communication.

Poor communication in emotionally sensitive situations can have tragic consequences. A patient with recurrent breast cancer in Hong Kong died by suicide after learning of prolonged treatment. In contrast, Canada integrates social workers and public crisis alerts to support at-risk individuals, showing the benefit of psychosocial care.

Medication errors commonly occur during care transitions, such as confusion between “.1 mg” and “1 mg,” or duplicate prescriptions from different providers. These stress the need for medication reconciliation, electronic prescribing, and clear discharge instructions.

Judgment errors also pose risks. One case involved delayed recognition of sepsis symptoms, only addressed after a nurse spoke up—emphasizing clinical vigilance and team collaboration.

Conclusion:
Preventing near misses requires structured communication, digital tools, simulation training, and a non-punitive culture that encourages reporting and system improvement.

Melisa Stublla, MD, is a recent medical graduate from the University of Prishtina in Kosovo, with growing interest in oncology, gynecology, internal medicine, and public health. She is deeply engaged in research and values evidence-based practice, having collaborated with international teams across multiple disciplines. Under the mentorship of Professor Patricia Tai, a leading figure in global oncology, Melisa is further motivated to pursue clinical research and contribute to global health efforts. She is dedicated to improving patient outcomes through scientific inquiry, innovation, and human-centered care.