# Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush. After giving the correct flush, the nurse who picked up the wrong vial asks what to do about the potassium chloride event. Which action is appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629758  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush.

After giving the correct flush, the nurse who picked up the wrong vial asks what to do about the potassium chloride event. Which action is appropriate?

## 보기

1. Write in the progress notes that an incident report was filed
2. Tell the charge nurse verbally, since the scanner stopped the error
3. Complete an incident report before the end of the shift **✔ 정답**
4. Place a copy of the incident report in the client's chart

**정답: 3**

## 해설

Events that are caught before reaching the client must still be reported so that the hazard (look-alike vials stored side by side) can be trended and fixed. The person who discovered the event completes the report promptly, usually before the end of the shift. The incident report is an internal quality document: it is not filed in, copied into, or mentioned in the client's record.

## 심화 해설

An error that is intercepted before the drug reaches the client is still a medication safety event. The barcode scanner prevented a potentially fatal bolus of concentrated potassium chloride, but the underlying hazard—look-alike vials stored in adjacent bins—remains present in the unit. Reporting the near miss allows the organization to identify and correct that system weakness before a future event reaches a client.

Why a near miss must be reported

Concentrated potassium chloride given as an IV flush can cause fatal hyperkalemia and cardiac arrest. In this situation, the nurse picked up the wrong vial but never drew up or administered the drug because the barcode scanner rejected it. The event is classified as a near miss or close call: an error that was caught before reaching the client.

Near misses are among the most valuable safety events to report because they reveal latent system hazards without the cost of client harm. The fact that two similar vials are stored side by side is a system design problem, not merely an individual nurse’s mistake. If the event is not reported, the storage arrangement stays unchanged and the next nurse may not be stopped by the scanner.

Key point! The purpose of an incident report is hazard identification and system improvement, not punishment of the individual clinician.

Who completes the report and when

The person who discovered or was involved in the event should complete the incident report. In this case, that is the nurse who picked up the wrong vial. The report should be completed promptly, while details are fresh and accurate. Completing it before the end of the shift is the appropriate and expected action.

Delaying the report risks losing important details about the environment, labeling, storage, and workflow that contributed to the error. A verbal report to the charge nurse alone is insufficient because it does not enter the formal quality and safety review system. The charge nurse may need to be informed for immediate unit awareness, but the written incident report is the required documentation.

Where the incident report belongs

The incident report is an internal quality and risk management document. It is used for trending, root cause analysis, and system redesign. It is not part of the client’s medical record.

The incident report must never be filed in, copied into, or mentioned in the client’s chart. The client’s record should contain only clinical facts about the client’s condition and care. If the client was not harmed, there is no clinical event to document in the progress notes. Writing that an incident report was filed would place a legal and quality document reference into the clinical record, which is inappropriate.

| Action | Appropriate? | Rationale |
| --- | --- | --- |
| Write in progress notes that an incident report was filed | No | Incident reports are internal documents and are never referenced in the client record |
| Tell the charge nurse verbally only | No | Verbal notification does not create a formal report for trending and system review |
| Complete an incident report before end of shift | Yes | The discovering nurse reports promptly while details are accurate |
| Place a copy of the incident report in the chart | No | Incident reports are not part of the medical record and must not be filed there |

System-focused perspective on medication errors

Medication safety research consistently emphasizes that errors arise from system failures rather than isolated individual negligence. Look-alike packaging and adjacent storage of high-alert medications are recognized system hazards. High-alert medications such as concentrated potassium chloride require special storage, labeling, and access controls precisely because a mix-up can be lethal.

Reporting this near miss triggers review of storage separation, labeling, and barcode scanning workflow, which protects future clients. The barcode scanner worked as intended in this event, but the near miss shows that the system still allowed the wrong vial to be picked up. A robust safety culture treats that as an opportunity for improvement.

Watch out! Do not confuse incident reporting with client documentation. The client’s chart records clinical assessment and interventions. The incident report records system events for quality improvement and is kept separate from the medical record.

## 임상 시나리오

Near-Miss Incident ReportingWhy intercepted errors still require documentation
A near miss is an error caught before reaching the client. It must still be reported because it reveals latent system hazards such as look-alike vials stored side by side.

The person who discovered or was involved in the event completes the incident report promptly, usually before the end of the shift.

CautionThe incident report is an internal quality document. Never file it in, copy it into, or mention it in the client's chart.

## 핵심 개념

- **near miss** — An error that was caught before reaching the client, also called a close call.
- **incident report** — An internal quality document used for hazard identification and system improvement, not for punishment.
- **concentrated potassium chloride** — A high-alert medication that can cause fatal hyperkalemia and cardiac arrest if given as an IV flush.
- **barcode scanner** — A technology that verifies medication identity and can intercept errors before drug administration.
- **latent system hazard** — An underlying system design weakness, such as look-alike vials stored side by side, that predisposes to errors.

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