NSG 633 Unit 2 near miss narrative analysis example

Once a Week, Entered as Once a Day: A Methotrexate Near Miss Told in Real Time and Then With Hindsight

Student Name

Department of Nursing, Herzing University

NSG 633: Safety and Quality

Instructor Name

January 21, 2026

Once a Week, Entered as Once a Day: A Methotrexate Near Miss Told in Real Time and Then With Hindsight

The Rule for the First Account

The event is a composite. A woman in her seventies with rheumatoid arthritis is admitted on a Sunday evening to a medical floor with a urinary tract infection. At home she takes methotrexate 10 mg by mouth once a week, on Mondays, as four 2.5 mg tablets. During admission medication reconciliation the drug is entered as methotrexate 10 mg by mouth daily. No dose is given. A pharmacist questions the order early Monday morning, and it is corrected before the first administration.

The first account below is written under one rule: nothing enters it that the admitting nurse could not have known or noticed at the moment it happened. Outcome knowledge changes how people judge earlier decisions, making the right cue look obvious and the competing demands look trivial (Henriksen & Kaplan, 2003). Keeping the rule visible is the only protection against that effect in a written account.

Account One: As It Happened

2015. The nurse has five patients and is receiving her second admission of the evening from the emergency department. The handoff report mentions the infection, the arthritis, and that the patient's daughter brought in a bag of medication bottles. The nurse has 35 minutes before the 2100 medication pass.

2030. The admission medication list is started from the emergency department's list, which shows eight medications, including "methotrexate 10 mg PO." The frequency field on that list is blank. The nurse opens the daughter's bag. The methotrexate bottle reads "Take 4 tablets by mouth once weekly on Monday." The nurse is at the same time answering a call light for another patient and listening to the daughter explain that her mother had not eaten since Friday.

2045. The reconciliation screen requires a frequency for every home medication before it can be signed. The default in the frequency dropdown is "daily," which is also the frequency for six of the other seven medications. The nurse selects the frequencies one by one and signs the list. Nothing on the screen looks unusual. The admitting provider converts the home list into inpatient orders at 2110, and methotrexate is ordered daily with the first dose due at 0900 Monday.

What the nurse held at the time: an eight-item list, a bottle label she had read once while answering a call light, a screen that required a frequency, and a daughter's story about poor intake. Nothing in the interaction flagged methotrexate as different from the other medications.

The Catch

At 0620 Monday, the overnight pharmacist verifying new orders saw methotrexate ordered daily. The pharmacy system displayed a caution banner for oral methotrexate with a daily frequency, and the pharmacist called the night nurse, who went to the bag of home medications still in the room and read the bottle aloud. The order was changed to weekly, Monday only, and then held by the provider during the acute infection.

Three conditions made the catch possible. The pharmacy software flagged the combination of drug and frequency, while the nursing reconciliation screen did not. The home bottle was still in the room rather than sent home with the family, so the label could be checked in minutes. And the pharmacist verified the order before the first dose, which on this floor happens for most overnight orders but not all of them. Remove any one of the three and the 0900 dose could have been given.

Account Two: With Hindsight

Written knowing the ending, the account looks different. The emergency department list had no frequency, which should have prompted a question. The bottle label said weekly, and the nurse read it. Oral methotrexate for non-cancer use appears by name among the high-alert medications that the Institute for Safe Medication Practices [ISMP] lists for acute care (ISMP, 2018), and daily dosing of oral methotrexate intended to be weekly is a well-documented cause of serious and sometimes fatal harm; an analysis of reported methotrexate errors found that the daily-for-weekly mix-up was the most common type of error (Moore et al., 2004). A nurse aware of that pattern would have stopped at the word methotrexate. The default of "daily" in the dropdown made the wrong answer the easy one.

Every one of those statements is true, and almost none of them was available to the nurse as a reason to act at 2045.

Comparison: What Was Reachable at the Time

Separating the two accounts shows which cues were genuinely reachable. The bottle label was reachable: it was in the nurse's hand. But it was read during a call light and a conversation, which is exactly the kind of divided attention in which information is seen but not processed. The blank frequency field was reachable, but it was blank for two other medications as well, so it did not single out methotrexate. The knowledge that methotrexate is a known daily-for-weekly risk was reachable only if the nurse had met it before; it is taught, but it was not on the screen.

The dropdown default and the missing reconciliation alert were not cues at all. They were conditions of the system, invisible to the nurse, and they appear only in the hindsight account. The phrase "should have noticed" would place them on the nurse.

Three changes would make the same catch more likely on an ordinary shift, without depending on the pharmacist's timing. The reconciliation screen could require a confirmed frequency for a short list of weekly drugs, with no default. Home methotrexate bottles could be kept on the unit until reconciliation is verified. And the admitting nurse could be given the reconciliation task at a protected time, rather than during the last 30 minutes before a medication pass. The first is the strongest, because it does not depend on anyone remembering.

The event was also reported. The night nurse filed a near-miss report before the end of the shift, under the category of reconciliation error with no harm, and named the dropdown default as a contributing condition in the narrative. Filing it matters for the reason Unit 1 of this course examined: a catch that is never recorded teaches only the people who were there, and the default that caused it stays in place for the next admission.

References

Henriksen, K., & Kaplan, H. (2003). Hindsight bias, outcome knowledge and adaptive learning. Quality and Safety in Health Care, 12(Suppl. 2), ii46-ii50. https://doi.org/10.1136/qhc.12.suppl_2.ii46

Institute for Safe Medication Practices. (2018). ISMP list of high-alert medications in acute care settings. https://www.ismp.org/recommendations/high-alert-medications-acute-list

Moore, T. J., Walsh, C. S., & Cohen, M. R. (2004). Reported medication errors associated with methotrexate. American Journal of Health-System Pharmacy, 61(13), 1380-1384. https://doi.org/10.1093/ajhp/61.13.1380