After a patient receives an incorrect insulin dose, the investigation finds similar look-alike insulin packages stored together. Which action best reflects system improvement?
Correct answer: A. Separate and clearly label the insulin storage areas
- A. Separate and clearly label the insulin storage areas
- B. Publicly identify the nurse who made the error
- C. Stop using insulin on the ward
- D. Tell staff to rely on memory when selecting insulin
Explanation
Separating and clearly labelling look-alike medicines addresses a system factor that contributed to the error. A just culture focuses on safer processes rather than public blame, unless deliberate unsafe conduct is involved.
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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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