Near miss: “an act of commission or omission that could have harmed the patient, but did not so as a result of chance (e.g., the patient received a contraindicated drug, but did not experienced an adverse drug reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation e.g., a lethal overdose was administered but discovered early, and countered with an antidote).” (Aspden, 2004)