The Clinical Nurse Consultant role in incident surveillance and patient safety: A case report

The Clinical Nurse Consultant (CNC) role emerged in New South Wales, Australia in 1986 as an advanced practice position. There is a growing body of literature seeking to articulate the multifaceted roles and responsibilities of the CNC within the Australian context. In this paper, we present a clinical case report that demonstrates how high risk medication administration errors via newly implemented syringe driver pumps, were identified and managed by a CNC. The CNC role was central in the identification of this series of medication errors that occurred across a number of hospitals, although these incidents could have been dismissed as human error. This report outlines the investigation, incident management process and subsequent release of a NSW state-wide Safety Alert. It also provides a discussion on the three key components for the successful management of a clinical incident investigation: leadership, teamwork and a 'no blame' culture. The specific role of the CNC in this case report provides evidence that the role of the CNC is pivotal to patient safety.