A "near miss" should be handled non-punitively, if possible, so that personnel will be more inclined to report these occurrences. It is also important to recognize that a process problem is usually due to either a process flaw or a managerial error. Perhaps sufficient safeguards are not in place to prevent an error, or perhaps personnel are not being assessed for the competencies they need to perform the job safely.
An environment of blame encourages a culture of secrecy about medical mistakes. Mandatory reporting laws have not overcome this secrecy, and they do not encourage efforts to find ways of avoiding errors.
Error reduction requires a commitment from the community to recognize and acknowledge that medical errors most often indicate systems problems, not people problems.
