Patient Safety
Patient safety questions test systems thinking and prevention of avoidable harm. The highest-yield topics are falls, pressure injuries, medication safety, identification, and communication failures.
Patient identification: Use two identifiers (name plus date of birth or ID number) before every intervention, medication and procedure. Never use the bed or room number as an identifier.
Falls: Assess risk on admission and when condition changes. Interventions: call bell within reach, bed in low position, brakes on, non-slip footwear, adequate lighting, regular rounding, and toileting assistance. Restraints are a last resort with legal authority, monitoring and documentation.
Pressure injuries: Use a validated risk assessment (e.g., Braden). Reposition regularly, keep skin clean and dry, use pressure-relieving surfaces, and provide nutrition and hydration. Document and stage accurately.
Communication and handover: Use structured handover (e.g., SBAR - Situation, Background, Assessment, Recommendation). Read-back for verbal orders and critical results reduces error.
Speak-up culture: Report near misses and incidents without blame; near-miss reporting prevents future harm. Follow the WHO surgical safety checklist and time-out before procedures.
Restraint and consent: Obtain informed consent, respect dignity, and use the least-restrictive option.
Traps
- Selecting a restraint when supervision or environmental modification would work.
- Using a room number as an identifier.
- Treating incident reporting as punitive - the safe answer is to report.
- Missing that a near miss must also be reported.
Rule of thumb
When a safety question asks what to do first, choose the action that immediately prevents harm to this patient (e.g., lower the bed, stay with the patient), then report and document.