• pharmacy intervention
• organizational learning
• medical error
• patient safety
• categorization

The categories used by organizations to classify and sort events are not trivial; they channel attention, shape interpretations, and serve as springboards for action. One example is the way in which organizations categorize small failures. Some organizations classify mistakes that have been caught and corrected with no untoward consequences—such as a near collision in aviation—as a “near miss”, a kind of failure that reveals how close the organization came to disaster. Other organizations do just the opposite. They look at a near miss and label it a “close call”, seeing it as evidence of success and the ability to avoid disaster.^1,2 The problem with this is that organizations that see mishaps as close calls often fail to treat these events as possible warnings that signal areas of vulnerability. By labeling a near miss as a “close call”, the cycle of learning is curtailed: beliefs that current operations are adequate to contain disaster are reinforced which, in turn, limits the search for information and also circumscribes actions to safeguard future operations.² Alternatively, when …