INTRODUCTION: Errors of medication are frequent causes of hazards to @entity1 . It has been suggested that containers that look alike constitute a risk of such errors. In this article, we present an example of how reporting incidents of potential risks, can be applied in their clinical management. MATERIAL AND METHODS: As part of a medical technology assessment project on risk management in a delivery department, the staff were encouraged to report incidents that could create a potential risk to @entity1 . The incidents were assessed by a project group as either a general problem to @entity1 safety or a solitary incident. If considered a general problem, procedures should be changed and implemented in the department. RESULTS: Two incidents were reported, where @entity6358 and @entity1425 were found in a box supposed to contain @entity2067 for new-born babies. These were considered a general problem by the project group, and the procedure for storing and managing @entity6358 and @entity1425 in the delivery department was changed to prevent new cases. DISCUSSION: Near misses occur more often than actual errors, and we argue that, as they are easier to discover, it is important to learn from them and thus prevent further incidents. A forum should be set up to exchange experiences of acknowledged risks, hazards, analytical results and preventive solutions.

[Risk management by reporting critical incidents. @entity2067 and XXXX mix-up at a birthing unit].

@entity1 :: ('9606', 'Species') :: ['patients', 'patient'] @entity1425 :: ('MESH:D004837', 'Chemical') :: ['adrenaline'] @entity6358 :: ('MESH:D004809', 'Chemical') :: ['ephedrine'] @entity2067 :: ('MESH:D014812', 'Chemical') :: ['vitamin K']
@entity6358 :: (MESH:D004809,Chemical) :: ['ephedrine']
