It was three in the morning on a ward that smelled faintly of bleach and overcooked vegetables. A first-year resident sat at the computer, the blue glow accentuating the worry lines he’d acquired too early. He had just ordered a dose of anticoagulant. Then a thought: did he mix up the lab values? Had he used the wrong parameter? The order hadn’t been carried out yet. The patient was still asleep, breathing evenly. The cursor blinked, demanding a decision. Cancel? Call the attending? Pretend it was fine?

That brief, suspended moment—before error tips into fact—may be one of the most consequential in medicine. It’s what we might call the almost-error.

We talk plenty about mistakes in medicine. There are commissions, reports, entire bureaucracies dedicated to tracking and preventing them. But what about the near misses, the actions aborted in time, the orders corrected at the last second, the missteps that dissolve back into the shadows? They don’t appear in the record. They don’t generate lawsuits. Yet for the people who commit them, they can be formative—and corrosive.

A 2020 phenomenological study in BMJ Open by Andrew Stuart Lane and Chris Roberts followed interns as they reflected on errors in prescribing and the difficult practice of disclosure. What emerges is a portrait of young doctors not just making mistakes, but rationalizing them in real time.

“Because there was a negative outcome, I guess, but was it reasonable? I think it was reasonable,” one intern told the researchers (Interview 5). Error, in this worldview, is defined not by intent or action, but by outcome. If the patient survives unscathed, was it really a mistake?

That reasoning is seductive. It keeps you moving through long shifts, lets you sleep a little at night. But it’s also dangerous. It domesticates risk until it seems harmless. Another intern, recalling a miscalculated heparin dose, brushed it off: “The guy was fine, he was just super… anticoagulated for a little while, which was probably a good thing for him” (Interview 1). Here the almost-error gets reframed as a blessing in disguise. An over-anticoagulated patient becomes an educational vignette, or worse, a sign of hidden competence.

Lane and Roberts describe this as apologetic justification—the subtle reframing that makes the unacceptable seem defensible. Then there’s the euphemism, what they call softening the blow. A patient rendered semi-conscious by opioids was described, with studied calm, as “just watching him sleeping it off” (Interview 9). Words can anesthetize more efficiently than drugs.

What’s striking is not that interns rationalize their mistakes—humans everywhere do that—but how quickly those rationalizations slip into the culture of medicine. “You make errors in terms of charting wrong doses,” another intern admitted, “They have all been picked up thankfully before they got administered” (Interview 1). In other words, near misses are just part of the job, background noise in the hospital machine. But this normalization of the almost-error erodes the moral weight of the event. The relief that nothing bad happened becomes an excuse to move on without reflection.

The study is blunt: “Rationalisation can lead to loss of context in apologising, which can be perceived as unempathic by the patients/families” (Lane & Roberts, 2020). Empathy leaks away when error is redefined as non-error. What remains is a professional stance that can look polished but sound hollow.

And yet, tucked inside the transcripts, there are flashes of something else. Lane and Roberts borrow the framework of the “competency matrix,” the four stages of learning from unconscious incompetence to unconscious competence. What the data reveal is the eerie in-between: “There are certain times when the light-bulb is potentially flashing, when they are starting to recognise something is not-quite-right, but have not quite realised why” (Lane & Roberts, 2020). These are the micro-moments of moral awakening, when the almost-error becomes a teacher. But without institutional scaffolding, those flashes often fade into defensive habits.

Doctors reading this will recognize the paradox. Formal policies on disclosure exist; scripts for apology exist. But in practice, they can flatten the very emotions that make an apology feel real. “I would say I’m sorry this has happened; I didn’t say I’m sorry during that time,” one intern admitted. “But I wouldn’t take ownership for the mistake that wasn’t mine” (Interview 2). Responsibility and accountability diverge. The institution asks for contrition; the individual hedges against liability.

The almost-error is where those forces collide. It doesn’t demand a disclosure, because nothing happened. But it demands something else, harder: reflection. To admit to yourself that you nearly harmed someone, that chance or vigilance—or luck—intervened. And then to carry that admission forward, not as guilt but as a kind of professional scar tissue.

This is not just about young doctors. Senior physicians normalize near misses too. Whole systems are built to mop them up without fuss. But if the culture of medicine continues to treat them as trivial, the profession forfeits one of its richest sources of ethical learning.

The intern on the night shift finally did cancel the order. He woke his attending, who sighed, corrected the chart, and told him to get some sleep. No one wrote anything down. The patient kept breathing peacefully.

But for the intern, that nothingness was everything. It was the almost-error, the invisible hinge where training becomes identity. If medicine is to be humane—not just safe, not just efficient—then it needs to honor those hinges. Because what we almost did, and chose not to do, shapes us as much as what we did.

Lane AS, Roberts C., Phenomenological study of medical interns reflecting on their experiences, of open disclosure communication after medication error: linking rationalisation to the conscious competency matrix. BMJ Open 2020;10:e035647. doi:10.1136/bmjopen-2019-035647