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Near miss report template

A short near miss report for events that almost caused harm. It asks what was about to happen, what stopped it, how serious it could have been, and what would prevent a repeat. It works for patient safety, workplace safety and equipment close calls, and takes minutes to finish. Near misses show hazards before someone is hurt.

Updated Oct 5, 20267 sectionsFree to print
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Before you start

When to use it

  • Something went wrong but was caught in time, like a wrong-patient label stopped at the scan or a forklift that braked short of a walker.
  • A safeguard worked and you want to note which: a time-out, barcode, guard, alarm or second person.
  • You found an unsafe condition before anyone was exposed: a spill, blocked exit, frayed cord or mislabeled bin.
  • An error reached a stage of the process but did not reach the patient or the worker.
  • You want a light reporting channel that staff will actually use.

How to fill it out well

  1. Report as soon as you can, even if you are not sure it counts. If you wonder whether to report it, report it.
  2. Sections 1 to 3 are enough for a quick report. A reviewer completes the rest.
  3. Say what happened, not who did it. Name the step, item or equipment involved.
  4. Say what stopped it. If nothing did and it was luck, say that. It is the most important answer on the form.
  5. Reviewers: reply fast, tell the reporter what was decided, and record any fix with an owner and a date.
  6. Check later that the fix held. Add the near miss to your trend data by location, shift and cause.

Near miss report template

Organization: ______________________   Site: ______________________

1. What and where
Date
Approximate time
Location or department
TypePatient safety: medicationPatient safety: procedure or surgicalPatient safety: fallPatient safety: identification or labelingPatient safety: equipment or deviceWorkplace safety: slip, trip or fallWorkplace safety: struck by or caught inWorkplace safety: chemical or electricalWorkplace safety: vehicle or forkliftSecurity or behaviorUnsafe condition (no event)Other
Reported by (optional)Leave your name off if anonymous reports are allowed. Add a contact to hear back.
I would like feedback on this reportNot hearing back is a common barrier to reporting (AHRQ PSNet).
2. What almost happened
What happened or nearly happened?Describe it in order. Facts only. No opinions about who was at fault.
What would have happened if it had not been caught?Describe the worst realistic outcome. It sets the priority.
Who or what was exposed (patient, worker, visitor, equipment)
Equipment, product or drug involved
How far did it get?If it reached the person with no harm, it is a no-harm event. Report it too.Hazard noticed, no eventEvent started and was stopped before anyone was exposedReached the person, but no harm followed
3. What stopped it
What caught it?'Luck' is a real answer and the most important one: it means no safeguard worked.A person noticedBarcode or scannerTime-out, checklist or double checkAlarm or alertGuard, interlock or other physical barrierPharmacist or supervisor reviewLuck: nothing in place stopped itOther
Who caught it (role)
What made it possible to catch?Name it so others can copy it: a label, a habit, a second person, an alert.
A safeguard that should have caught it was missing or did not work
4. How serious could it have been
Worst credible outcomePick the worst realistic outcome, not the worst imaginable. This is the severity half of a risk matrix.No harmMinor injury or first aidModerate injury or treatmentSevere injury, permanent harm or death
How likely is it to happen again?Think about how often the conditions line up: shift, staffing, equipment, product.RarePossibleLikelyAlmost certain
Has this happened before?First time I know ofSeen beforeHappens often
Priority (reviewer)Use your site's risk matrix to combine severity and likelihood.LowMediumHigh
5. Contributing conditions
Staffing, workload or time pressureCheck what applies. These describe conditions, not people.
Interruption or distraction
Labels, layout or look-alike items
Equipment, tool or maintenance condition
Procedure unclear, or hard to follow as written
Communication or handoff
Environment: lighting, noise, clutter or a spill
Anything else
6. Suggested fix
What would prevent this from happening again?Ask the people who do the work. Fixes that change the setup beat reminders.
Type of fix suggestedRemove the hazard or the stepReplace with something saferAdd a physical barrier, guard or forcing functionChange the layout, label or defaultAdd a checklist, double check or alertChange a procedure or add trainingNot sure
Immediate action already taken
Equipment removed from service, or the area made safe
7. Review (manager)
Date received
Reviewed by
DecisionFixed on the spotCorrective action assignedNeeds formal investigationMonitor and trendNo action: reason recorded
Owner and due date
Feedback given to the reporter
Added to the QAPI or safety committee log
Reviewer signature
Editable copy

Get this template by email.

We send an editable version you can adapt to your policies, plus a short checklist. No patient information, ever.

Tips

  • Thank people for reporting. AHRQ PSNet says lack of feedback is a commonly cited barrier to reporting, and a short reply beats a poster.
  • Record the catch as well as the miss. Knowing which safeguard worked tells you what to protect.
  • Track by location, shift and equipment. Several near misses in one place are a forecast. OSHA encourages investigating close calls as well as injuries.
  • Keep it blame-free. A just culture separates honest mistakes from reckless acts so people keep reporting.

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Questions

About this template.

Something we missed? Ask us, and a person answers.

What is a near miss?

An event or condition that could have caused harm but did not, because it was caught in time or by chance. OSHA calls close calls incidents where a worker might have been hurt had things been slightly different. NCC MERP category B did not reach the patient.

Is a near miss recordable or reportable?

A close call with no injury is not recordable under OSHA's rule, which covers work-related injuries and illnesses. OSHA encourages investigating close calls. CMS survey guidance for ASCs expects centers to find near-miss errors. Some states require certain reports, so check yours.

Why do near miss reports matter?

They show hazards and weak safeguards while the cost is still zero. OSHA says investigations should cover close calls as well as injuries, and look for root causes, not blame. AHRQ PSNet adds that reporting works best with feedback to reporters.

How do I get staff to report near misses?

Make reporting short, safe and answered. A form with few fields, an anonymous option, a visible reply and a no-blame review removes the usual reasons people stay quiet. See how to get staff to report near misses.

What is the difference between a near miss and a no-harm event?

A near miss is caught before it reaches the patient or worker. A no-harm event reaches them and no harm follows. Both deserve a report, and the second shows a safeguard that failed. This form asks how far the event got.

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