Synopsis
Recognise how people, tasks, tools, environment and organisation interact, apply controls to immediate risk, and learn from incidents through proportionate system-based responses.
- Patient safety incidents arise from interactions across a work system; look beyond the last person who touched the process to understand why harm became possible.
- Human performance varies with fatigue, workload, interruption, unfamiliarity and competing goals; design checks and escalation around this predictable variability.
- When risk is immediate, make the patient safe first, call for help, preserve essential evidence and communicate openly through local procedures.
Reasoning priorities
Identify current patient harm, ongoing exposure and anyone else at risk.
Stabilise, stop the hazardous process and escalate clinically before beginning a detailed investigation.
Worked reasoning
A nurse notices that a look-alike ampoule of a higher concentration has been selected immediately before administration; no drug reaches the patient.
- Stop administration, confirm the patient is unharmed, secure the ampoule and prescription details, inform the responsible clinician and manage any continuing stock risk immediately.
- Record factual chronology and report the near miss, including location, workload, storage, packaging, electronic display and how the discrepancy was detected.
- Map defences: selection, preparation and check stages; identify why the wrong item was easy to choose and why the final check succeeded this time.
- Implement an owned control such as physical separation or purchasing and system constraints, then audit selection errors and staff workarounds to verify risk reduction without delaying urgent care.