A root cause review finds that staff regularly select the wrong patient from an electronic medication list because patients with similar names appear next to each other. Which preventive action is strongest?
Correct answer: C. Separate similar names and add a second identifier
- A. Tell nurses to concentrate more carefully
- B. Issue a warning to the nurse involved
- C. Separate similar names and add a second identifier
- D. Ask patients to remember their medicine names
Explanation
Separating similar names and requiring a second identifier changes the system to make error less likely. Telling staff to be more careful relies only on memory and does not remove the underlying hazard.
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About Quality and Patient Safety
Quality and patient safety include standards of care, quality assurance, continuous quality improvement, audits, indicators and patient feedback. The subject also covers medication errors, falls, infections, communication failures, incident reporting, root cause analysis and preventive actions, distinguishing system improvement from assigning blame to an individual.
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