A nurse detects that a blood unit is labeled for a different client before the unit reaches the bedside. No transfusion occurs. Which action is appropriate?
1Submit a prompt safety-event report describing how the mismatch was detected✓ Correct answer
2Document the near miss in the client record and identify involved staff
3Discard the unit and take no further action because the client was not harmed
4Wait for the blood bank to investigate before notifying the charge nurse
Explanation
A mismatch caught before transfusion is a near miss. Reporting it through the facility safety-event system supports investigation of the process and prevention of future harm even though the error did not reach the client.
Quick answer Report the near miss through the safety-event system. Early detection prevented harm, but the process failure still needs organizational review.
Why this is correct Near misses reveal the same hazardous system weaknesses that can cause an adverse event next time. A factual event report allows the organization to trace labeling, transport, and verification steps and improve safeguards without placing the report itself in the clinical record.
Easy analogy or mental picture A near miss is like a train stopped just before a damaged section of track. No crash occurred, but the broken track still must be reported and repaired; the comparison does not determine individual accountability or replace facility policy.
Memory hook Caught before harm still means report the hazard and learn from the system.
NCLEX decision rule For a near miss, first protect the client and secure the unsafe product, then use the designated safety-reporting process. Do not hide the event, blame people in the chart, or assume no injury means no report.
Why the other choices are wrong The client record should contain clinically relevant care, not the confidential event report or staff blame. Discarding evidence or waiting passively loses information needed for a timely systems review.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
AHRQ PSNet: Strategies for Investigating Patient Safety EventsAgency for Healthcare Research and Quality Patient Safety Network, reviewed 2025