NR 544 Week 2 Near Miss Write-Up Example

Near Miss Write-Up: A Dose of Insulin Carried to the Wrong Same-Surname Patient, Stopped by the Bedside Barcode Scan, and Closed Under a Code That Meant Nobody Needed to Read It

Student Name

College of Nursing, Chamberlain University

NR 544: Quality and Safety in Healthcare

Instructor Name

Month Day, Year

Near Miss Write-Up: A Dose of Insulin Carried to the Wrong Same-Surname Patient, Stopped by the Bedside Barcode Scan, and Closed Under a Code That Meant Nobody Needed to Read It

What Did Not Happen

At 2110 on a weeknight, a registered nurse on our 30-bed adult medical unit carried a prepared dose of rapid-acting insulin into room 14, intending it for a patient in room 12. The two patients shared a surname. The nurse had been caring for the patient in room 12 for three shifts and was covering room 14 for a colleague on break. The dose was scanned at the bedside against the wristband of the patient in room 14, the scanner displayed a wrong-patient alert and the nurse stopped. The insulin never reached the patient. The nurse returned the dose to room 12, scanned it correctly and gave it. Neither patient was harmed.

That paragraph is the whole event as it happened, written without judgment. The rest of this paper asks what stopped it, whether the same thing would stop it again and what the record made of it.

Name the Catch

A near miss is stopped by one of three things: a person who happens to look twice, a step built into the routine that makes the error visible, or luck, meaning the event simply runs out of road before harm. This interception was the second kind. Barcode medication administration requires the nurse to scan the patient's wristband and the medication before giving a dose, and the system compares them with the active order. It stopped this error without depending on anyone's alertness at 2110. A large before-and-after study found that barcode-assisted administration substantially reduced medication administration errors when used as designed (Poon et al., 2010).

The distinction matters. A catch that depends on a person being unhurried cannot be scheduled; one built into the work is present on every shift, as long as the work is done the designed way.

Would It Catch It Again

The strongest test of a near miss is to replay it on a worse night. Suppose the unit is short two nurses, a rapid response is under way down the hall and the wristband on the patient in room 14 is creased and will not scan. On our unit, the common response to an unreadable wristband is to scan a printed label sheet kept at the nurses' station, which carries each patient's barcode. Koppel et al. (2008) described this kind of workaround, among others, in a study of barcode medication administration, noting that it defeats the patient check the system was built to provide. If the nurse had scanned a label sheet for room 12 while standing in room 14, the scanner would have accepted the dose.

So the honest answer is conditional. The catch is reliable when the wristband scans and unreliable on precisely the kind of night when errors are most likely. That condition, not the nurse's momentary confusion, is the finding worth recording.

There is a further reason to take the conditional answer seriously. The night on which this event happened was an ordinary one, with full staffing and no emergency on the unit. The nurse was covering a single room for a colleague on a meal break, a routine arrangement that happens dozens of times a day. If a wrong-patient error reached the bedside under those conditions, the same pairing on a short-staffed night would meet a nurse covering more rooms, with less time to look, and a wristband more likely to have been worn for days. The safeguard's reliability falls exactly as the risk rises.

The Entry as Filed

The nurse entered the event in the incident reporting system before the end of the shift. The category selected was "Medication, wrong patient." The system then asked whether the event reached the patient, and the answer was no. It asked for a harm level, and the only honest choice was "no harm, did not reach patient." The free-text box held four sentences: the two patients shared a surname, the nurse was covering for a break, the scanner alerted and a name alert had been written on the whiteboard two days earlier.

The entry was closed by the unit manager four days later with the note "Reviewed with staff member. Barcode scanning worked as intended." Nothing in the closure mentions the shared surname, the covering assignment or the label sheets.

Arguing the Code

The severity code did what severity codes do: it decided where the entry went. Under our system's rules, a medication event that does not reach the patient and causes no harm is reviewed at the unit level and closed; only events at higher levels are routed to the patient safety office. That rule makes sense for volume, since the office could not read every entry. But in this case it meant that the one part of the event worth studying, a same-name pairing combined with a covering assignment, was read only by a manager whose reasonable conclusion was that the safeguard had worked.

Near miss reporting systems in other industries treat events like this one as valuable precisely because nobody was harmed, since the conditions can be studied without the defensiveness that follows an injury (Barach & Small, 2000). I would argue for coding this entry as a near miss with a known contributing condition, not simply as no harm. The system's current codes do not offer that option, so a practical alternative is a rule that any wrong-patient near miss is copied to the patient safety office regardless of harm level. The four sentences in the free-text box contained the whole lesson, and under the current code they were routed to a reader who had no reason to look for it.

What the Write-Up Recommends

The write-up does not recommend a new policy on patient identification; the existing policy was followed, and the scanner enforced it. It recommends three smaller things. First, recode or copy wrong-patient near misses to the patient safety office. Second, count how often label sheets are used to scan doses on this unit, since the catch depends on their not being used. Third, add a note to the covering-nurse handoff when two patients on the assignment share a surname. Each is aimed at the conditions the event exposed, not at the nurse who carried the dose.

References

Barach, P., & Small, S. D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ, 320(7237), 759-763. https://doi.org/10.1136/bmj.320.7237.759

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115