A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?
A) identifying systemic factors on the unit that may have contributed to the event
B) reinforcing the standards for nursing care to staff members who were involved
C) ensuring that the client's nurse is held accountable and educated about best practice
D) communicating the potential consequences of the near miss to the client involved
Ans: A
Feedback:
Central to creating a culture of safety is the need to identify systemic factors that may contribute to errors or near misses. Communicating with the client is necessary, but identifying systemic factors is a priority because of the implications for future clients. Focusing on the nurses who were directly involved demonstrates a narrow and short term perspective of safety, which may be perceived as punitive.
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