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 ofthis 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.

Item Type:	Refereed Article
Keywords:	Clinical Nurse Consultant, nurse leader, patient safety, infusion pump, syringe driver pump, clinical incident, human factors
Research Division:	Health Sciences
Research Group:	Nursing
Research Field:	Acute care
Objective Division:	Health
Objective Group:	Provision of health and support services
Objective Field:	Nursing
UTAS Author:	Colgan, J (Ms Jacqueline Colgan)
ID Code:	112058
Year Published:	2017 (online first 2016)
Deposited By:	Health Sciences
Deposited On:	2016-10-25
Last Modified:	2018-02-07
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