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Difficulty: MediumAccident, Error, and Injury Prevention

A nurse is implementing safety protocols on a telemetry unit. Which nursing action correctly demonstrates the principles of accident, error, and injury prevention?

  1. A
    Applying bilateral soft wrist restraints to a delirious client attempting to remove a nasogastric tube before trialing a bedside sitter or a camouflage sleeve.
  2. B
    Delegating the initial admission fall risk and skin integrity assessments for a newly transferred client to an experienced unlicensed assistive personnel.
  3. Requesting a second registered nurse to independently verify the pump settings before changing the rate of a continuous intravenous heparin infusion.Answer
  4. D
    Completing routine electronic charting for a stable client before immediately assessing another client whose cardiac monitor suddenly displays sustained ventricular tachycardia.

Answer

Requesting a second registered nurse to independently verify the pump settings before changing the rate of a continuous intravenous heparin infusion.
High-alert medications, such as continuous intravenous heparin, carry a significant risk of causing catastrophic client harm if administered incorrectly. To prevent medication errors, safety protocols mandate an independent double-check by a second registered nurse before initiating or modifying the infusion.

Step-by-Step Solution

1
Evaluate each nursing action against national patient safety standards and error prevention protocols.
Identify which action mitigates risk effectively without violating scope of practice, prioritization rules, or restraint guidelines.
Accident and error prevention requires strict adherence to established safety guidelines.
2
Analyze the action involving high-alert medications (heparin).
Recognize that heparin has a narrow therapeutic index and carries a high risk for severe injury if miscalculated.
An independent double-check is a mandatory evidence-based practice to prevent medication errors with high-alert drugs.
3
Identify the safety violations in the remaining options.
The other options demonstrate skipping required restraint alternatives, inappropriate delegation of an initial assessment, and ignoring an acute airway/breathing/circulation (ABC) priority.
Eliminating unsafe practices confirms the correct application of error prevention.

Key Concept

High-Alert Medication Safety and Error Mitigation
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Topics

Accident, Error, and Injury Prevention

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