In clinical practice, not every error leads to harm—but every near-miss offers a valuable lesson. Even small communication gaps in busy healthcare settings can impact patient safety, making timely correction essential.
During my time in the outpatient department (OPD) of a government hospital, I encountered a near-miss that changed my approach to patient counseling. While dispensing medication to an elderly patient 
, she asked if it could be taken with milk.
In the crowded setting, she assumed I had agreed. Shortly after, I recognized the misunderstanding and clarified that the medicine should not be taken with milk. Thankfully, the error was corrected in time.
This experience reinforced an important point dispensing medication is not just a task, but a responsibility that includes clear communication 
. Factors like patient age, noise, and assumptions can easily lead to errors.
Since then, I make it a point to:
Clearly explain instructions
Repeat key precautions
Confirm patient understanding
Briefly discuss relevant lifestyle advice
Near-misses are not failures—they are opportunities to improve how we communicate and care. Ensuring patient understanding is just as important as prescribing the right treatment.
Have you experienced a near-miss that changed your approach to patient care?
MBH/AB