Chart — Patient Safety
Patient Safety Checklist
A comprehensive patient safety checklist covering identification, medication verification, fall precautions, infection control, and documentation — organized for easy scanning at the bedside and NCLEX review.
Educational use only. Safety protocols vary by institution, unit, and patient population. This checklist reflects general evidence-based safety principles. Always follow your facility's specific policies, Joint Commission standards, and National Patient Safety Goals. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Patient Identification
| # | Safety Check | Key Point |
|---|---|---|
| 1 | Use two patient identifiers | Full name + date of birth or full name + medical record number before every medication, procedure, or specimen |
| 2 | Ask patient to state name (don't suggest it) | Say “Please tell me your name” — never “Are you Mrs. Jones?” — patients may confirm incorrectly when confused or anxious |
| 3 | Room number is never an identifier | Room numbers change; patients transfer; room number is not a patient-specific identifier |
| 4 | Verify armband before every medication administration | Even for familiar patients — armbands may be on the wrong patient after procedures or transfers |
| 5 | Blood product verification requires two nurses | Independent two-nurse verification of blood type, unit number, patient ID, expiration date before transfusion initiation |
Medication Verification
| # | Safety Check | Key Point |
|---|---|---|
| 1 | Verify all 10 rights before administering any medication | Right patient, medication, dose, route, time, documentation, reason, response, right to refuse, education |
| 2 | Scan barcode or check armband before giving | Barcode medication administration (BCMA) reduces errors at the final check point — never override without investigating the cause |
| 3 | Independent double-check for high-alert medications | Insulin, anticoagulants, opioids, vasoactive drips, chemotherapy — second RN independently verifies drug, dose, rate, and patient |
| 4 | Check labs before administering electrolyte-sensitive medications | Digoxin: check potassium and HR. Insulin: check glucose. Anticoagulants: check INR or aPTT. Lithium: check lithium level. |
| 5 | Never give concentrated KCl IV push | Concentrated potassium chloride given undiluted IV is immediately fatal. Always diluted; always pharmacy-prepared when possible; max rate 10 mEq/hr peripheral. |
| 6 | Report all errors AND near-misses | Near-misses reveal system vulnerabilities. Report without fear of blame. Notify provider, monitor patient, and complete incident report. |
Fall Precautions
| # | Safety Check | Key Point |
|---|---|---|
| 1 | Assess fall risk on admission and with status changes | Morse Fall Scale or Hendrich II; document score; reassess after falls, new medications, or functional changes |
| 2 | Bed in lowest position; brakes locked | Universal precaution for all patients — not just high-risk. Lock before you leave the room. |
| 3 | Call light within reach at all times | Verify before leaving the room. Educate patient and family to call before getting up. |
| 4 | Non-slip footwear; clear pathway to bathroom | Non-slip socks for all patients. Remove IV poles, equipment, and other trip hazards from the walking path. |
| 5 | Hourly rounding (toileting, pain, positioning, call light) | Proactive rounding reduces call light use and unassisted fall attempts. Use the 4 Ps: Pain, Position, Personal Needs, Placement. |
| 6 | Bed or chair alarm for high-risk patients | Alarms supplement — do not replace — nursing surveillance. Alarms must be heard and responded to immediately. |
| 7 | Medication review for fall-risk contributors | Sedatives, opioids, antihypertensives, diuretics, and anticholinergics increase fall risk. Collaborate with provider for de-escalation when safe. |
Infection Control
| # | Safety Check | Key Point |
|---|---|---|
| 1 | Hand hygiene before and after every patient contact | Most important infection prevention measure. Soap and water required for C. diff and norovirus — ABHR does not kill spores. |
| 2 | Standard precautions with every patient | Treat all blood, body fluids, and non-intact skin as potentially infectious — regardless of diagnosis or test results |
| 3 | Apply correct transmission-based precautions | Contact (MRSA, C. diff), droplet (flu, meningitis), airborne (TB, measles, varicella) — in addition to standard precautions |
| 4 | Daily line necessity assessment | Central lines, Foley catheters, and ETTs should be removed as soon as clinically no longer necessary — every extra day increases infection risk |
| 5 | Maintain closed drainage systems | Foley drainage bag below bladder level; do not disconnect tubing except to change; keep drainage bag off the floor |
Documentation
| # | Safety Check | Key Point |
|---|---|---|
| 1 | Document in real-time (or as close as possible) | Never pre-chart or back-chart without clear timestamps. Document what was done, when, and the patient's response. |
| 2 | Read-back all verbal and telephone orders | Read back entire order to provider; document “read back and verified”; provider must co-sign within required timeframe |
| 3 | Never alter or white out prior documentation | Draw a single line through errors; add correction with date, time, and signature. Medical record falsification is a serious legal violation. |
| 4 | Use only approved abbreviations | Avoid ISMP Do-Not-Use list: “U” for units, “IU,” “QD,” trailing zeros (1.0 mg), and naked decimal points (.5 mg) |
| 5 | Structured handoff communication (SBAR) | Use SBAR format for all handoffs and provider notifications. Include current status, pending tasks, and anticipated changes. |
Related Resources
Patient Safety Principles GuideIn-depth coverage of all patient safety domains with NCLEX scenarios
Open →Never Events ReferenceSerious preventable patient safety events and prevention strategies
Open →High-Alert Medications ReferenceISMP high-alert medication list with nursing safety considerations
Open →Insulin Administration and SafetyInsulin — the highest-risk high-alert medication in hospital settings
Open →Standards & sources
Fact-checked Jun 21, 2026This page is written to align with Joint Commission National Patient Safety Goals. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →