LessonsSafety and Infection Prevention and Control

Preventing the errors that actually happen

Apply the checks that stop the common errors — wrong client, wrong site, wrong drug — and say what to do after one has happened.

Two identifiers, every time

Before any medication, procedure, specimen or transfusion, the client is identified by two identifiers that are not the room number and not the bed. Name and date of birth is the usual pair, checked against the band and against what the client says.

Asking "are you Mr Ahmed?" is not identification. A client who is drowsy, hard of hearing, or simply being agreeable will say yes. Asking them to state their name and date of birth is.

The time-out, and high-alert drugs

Before a procedure the whole team stops and confirms the right client, the right procedure and the right site, with the site marked. Anyone present may stop it, and a nurse who notices a discrepancy raises it then rather than afterwards.

Some medications carry enough risk that they get an extra check by a second nurse: insulin, heparin and other anticoagulants, concentrated electrolytes, opioids, and chemotherapy. Concentrated potassium chloride is never stored on a unit as a ready-to-use vial, for the same reason.

Look-alike sound-alike names — hydralazine and hydroxyzine, celecoxib and citalopram — are separated in storage and written with the differing part emphasized. Alphabetical order puts them next to each other, which is exactly the problem.

After an error

  1. Assess the client, and treat whatever the error has caused. This comes before anything administrative.
  2. Notify the provider, and follow whatever is prescribed.
  3. Complete an incident report, factually, describing what happened.
  4. Document the clinical facts in the client's record — the assessment, the notification, the response.

The incident report is not referred to in the client's record and is not part of it: it is an internal safety document. Recording "incident report filed" in the chart pulls it into the legal record, which is the opposite of what it is for.

Worth remembering

  • Two identifiers, neither of them the room or the bed, and never a yes-or-no question.
  • High-alert drugs get an independent second check; concentrated potassium is not stocked ready to use.
  • After an error: assess the client first, then notify, then report, then document.
  • The incident report is never mentioned in the client's own record.
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