# Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants. A staff nurse gave a postpartum mother another mother's iron tablet. The mother was unharmed after assessment. While reviewing the event, the charge nurse reminds the staff of the incident reporting rules. Which statement is correct?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants.

A staff nurse gave a postpartum mother another mother's iron tablet. The mother was unharmed after assessment. While reviewing the event, the charge nurse reminds the staff of the incident reporting rules. Which statement is correct?

## 보기

1. Errors that reached a mother and harmed her are the only ones that need a report
2. A near miss caught before it reached the mother also needs a report **✔ 정답**
3. The nurse's notes should state that an incident report was filed
4. The charge nurse, not the nurse involved, writes the incident report

**정답: 2**

## 해설

Incident reports are made promptly and objectively by the person involved in the event or the person who discovered it. Near misses must be reported too, because they reveal hazards before anyone is harmed. The report is a confidential quality tool: the chart records the facts of the event and the care given, but it never mentions the report.

## 심화 해설

Incident Reporting in the Postpartum Ward

The correct answer is 2. A near miss caught before it reached the mother also needs a report.

In this scenario, a staff nurse gave a postpartum mother another mother's iron tablet. The mother was assessed and found unharmed. Even though no harm occurred, the event still requires an incident report because it represents a near miss or a no-harm event that reached the patient. Incident reporting systems are designed to capture hazards and system weaknesses before they cause actual injury, not merely to document harm after it occurs.

Why Near Misses Must Be Reported

A near miss is an event that could have caused harm but did not, either by chance or because it was caught in time. In this case, the wrong iron tablet reached the mother, but she was unharmed. This is still a reportable event because it reveals a breakdown in the medication administration process—specifically, a failure in patient identification or medication verification. Reporting near misses allows the unit to identify latent errors in workflow, staffing, labeling, or communication before a future event causes actual patient harm.

The qualitative systematic review by Hamed and Konstantinidis [1] emphasizes that incident reporting in health care serves to prevent error recurrence and ultimately improve patient safety. If only harmful errors were reported, the system would miss the very signals that allow prevention. Near misses are often more frequent than harmful events, and analyzing them provides a richer source of information about system vulnerabilities.

Who Writes the Incident Report

The incident report is written promptly and objectively by the person involved in the event or the person who discovered it. In this scenario, the staff nurse who administered the wrong tablet should write the report, not the charge nurse. The charge nurse may review the report, provide support, and facilitate follow-up, but the direct account of the person involved is essential for accuracy. This makes option 4 incorrect.

Confidentiality and the Medical Record

Watch out! The incident report is a confidential quality improvement tool, not part of the patient's medical record. The nurse's notes in the chart should document the facts of the event—what was administered, the assessment findings, and the care provided—but should never mention that an incident report was filed. This makes option 3 incorrect. The report itself is protected from legal discovery in many jurisdictions precisely because it is used for internal quality review, not for documenting care.

The South African guideline implementation study  reinforces that incident reporting is embedded in national patient safety guidelines and is intended to be a systematic, non-punitive process. The cross-sectional survey by Ponticelli and colleagues  further notes that nurses are strategically positioned to identify unsafe conditions, near misses, and adverse events, underscoring that reporting is a core nursing responsibility regardless of whether harm occurred.

Comparison of Event Types and Reporting Requirements

| Event Type | Definition | Report Required? | Example in This Scenario |
| --- | --- | --- | --- |
| Adverse event with harm | Error reached the patient and caused injury | Yes | Mother developed a reaction to the wrong iron tablet |
| No-harm event | Error reached the patient but no injury occurred | Yes | Mother received another mother's iron tablet but was unharmed |
| Near miss | Error was caught before reaching the patient | Yes | Nurse noticed the wrong tablet before giving it |
| Hazardous condition | Unsafe situation that could lead to an error | Yes | Medication cart with unlabeled or mislabeled iron tablets |

Clinical Application for the Postpartum Ward

In a 30-bed postpartum ward, iron supplementation is a routine but high-volume medication task. The risk of mix-ups increases with patient turnover, similar medication names, and interruptions during medication passes. A robust incident reporting culture on the unit means that every wrong-patient medication event—whether caught before administration or discovered after—is reported, analyzed, and used to redesign the medication administration workflow.

The Saudi Arabian systematic review  identifies factors influencing incident reporting and emphasizes evidence-based strategies to strengthen reporting culture. These include reducing fear of blame, providing feedback after reports are submitted, and ensuring that reporting leads to visible system changes. When nurses see that near-miss reports result in improved labeling, barcode scanning, or double-check protocols, they are more likely to report consistently.

Key point! The purpose of incident reporting is system learning, not individual punishment. The charge nurse's role is to reinforce that all events—harmful, no-harm, and near miss—are reportable, and that the report is separate from the patient's chart. The chart documents the clinical facts; the incident report feeds the quality improvement process.References (research sources)

- [1]Barriers to Incident Reporting among Nurses: A Qualitative Systematic Review.Meta-analysis/systematic reviewHamed MMM, Konstantinidis S (2022) · DOI: 10.1177/0193945921999449

## 임상 시나리오

Incident Reporting on the Postpartum WardNear misses are reportable events
A near miss is an event that could have caused harm but did not, either by chance or because it was intercepted. It must be reported even if the mother was unharmed. Reporting near misses reveals latent errors in medication administration, such as failures in patient identification or verification.

The incident report is written by the person involved in the event or the person who discovered it. It is a confidential quality tool, not part of the patient's chart.

CautionNever document in the nurse's notes that an incident report was filed. The chart records only the facts of the event and the care given.

## 핵심 개념

- **Near miss** — An event that could have caused harm but did not, either by chance or because it was caught before reaching the patient.
- **Incident report** — A confidential quality improvement tool used to document events and hazards; it is not part of the patient's medical record.
- **No-harm event** — An error that reached the patient but did not cause injury, still requiring reporting to identify system weaknesses.
- **Latent error** — A hidden system or process defect that may contribute to future errors if not identified and corrected.
- **Quality improvement** — Systematic use of incident data to analyze patterns and prevent recurrence of errors.

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