Form

Near-miss Report Template & Triage Rubric

An interactive near-miss report that captures essential details, records immediate containment actions, guides a simple triage using likelihood and impact, suggests priority, and records recommended owners and follow-up actions. Includes a short non-punitive guidance note to encourage reporting and high-quality narratives.

Interactive Tool

Near-miss Report & Triage

Why this matters: Near misses are often the best early warning of systems problems. This form is non-punitive — the goal is learning and prevention. Give a clear, factual account of what happened, what you observed, and what you did immediately to keep patients safe.

Confidentiality note: You may remain anonymous if desired. If you’re unsure whether to report, err on the side of reporting — we’d rather learn early than miss a preventable harm.

Optional — leave blank to report anonymously.
E.g., RN, phlebotomist, unit clerk, physician. Helps with follow-up context.
Use local date/time format. If unsure, give the best estimate.
E.g., ED triage, OR 2, Med-Surg unit.
Describe what happened in plain language. Focus on facts (who, what, when, where). Avoid blaming language. Example: 'Medication prepared for patient A was placed at medication station B and almost administered to patient C before being caught.'
List the key steps or moments that led to the near-miss. Helpful for people who will triage and investigate.
E.g., bedside nurse, pharmacy tech, float nurse. Use roles to preserve privacy where appropriate.
If applicable, provide product name, model or med name and dose.
Check all that apply — these actions protect patients right now.
Describe any additional immediate steps taken.
Select the best option that describes patient outcome.
1 = Highly unlikely, 5 = Almost certain
1.0 10.0
1 = Negligible, 5 = Catastrophic
1.0 10.0
Use this field to explain why this report may need urgent attention (e.g., repeated occurrence, vulnerable patient, near administration of high-risk medication). Suggested quick rule: Sum of Likelihood + Impact >= 8 -> Consider 'High' or 'Urgent'.
Reviewer chooses priority after reviewing the report. Suggested rule above is only guidance.
Select one or more roles to take follow-up ownership. Local teams may assign specific names after claiming ownership.
If you chose 'Other' or want to name a specific person for follow-up, enter their role or name.
Suggest immediate fixes and longer-term changes (e.g., signage, checklist change, training, equipment repair). Be concise.
If 'Yes', the system should flag this report for earlier review and notification.
Enter number of days for expected follow-up or a target date text (e.g., '7 days' or '2026-09-01').
If you provided contact details and consent, the team may ask clarifying questions.
Use this for contextual information you do not want published in shared summaries. Visible only to reviewers/owners.
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