Quality AND Safety IN Medicine

Meet the patient

An 78-year-old woman with multimorbidity is admitted with a fall. By day three she is in delirium, has developed a stage-two pressure injury, and was nearly given a double dose of warfarin because her medication reconciliation at admission missed a recent GP change. The nurse is upset. The registrar wants to know who to blame.^[1][14]

The question that decides whether this happens again is not who made the mistake — it is which layers of the system failed to catch it. The warfarin error is not a careless nurse; it is a missing medication-reconciliation step at a transition of care, a look-alike drug name, and an interruption during prescribing. Fix the layers and the nurse does not need to be perfect.^[5][9]

References14ShowHide

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