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Healthcare risk assessment

Nursing Practice and Advanced Nursing Roles Risk Assessment: Medication, Deterioration and Scope Controls

A worked example of how an inpatient nursing team finds, scores and controls the risks that arise in routine practice and in advanced nursing roles, from medication errors and missed deterioration to privacy, staffing, equipment and scope of practice boundaries.

Updated November 2026 8 hazards assessed Review every 6 months Highest risk: Critical to Medium
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Executive summary

This assessment shows how an inpatient nursing team can find, rate and control the risks that matter most to patient safety and to the trust placed in advanced nursing roles. Eight risks were chosen because they are plausible in everyday ward practice. Missed deterioration and medication errors carry the highest inherent scores, because they can cause serious harm quickly. Each risk is scored before controls and again after existing and added controls. Most risks fall to Medium or Low once the proposed controls are in place, but missed deterioration stays at High because the impact remains severe. The first actions are a bedside handover for raised scores, barcode checks for high-risk medicines and a protocol check before advanced orders are signed. The ward is a teaching example, so every score illustrates method, not a real service.

Focus area
Nursing practice and advanced nursing roles
Setting
Adult inpatient ward and supporting community nursing service with advanced practice nurses working alongside ward teams
Method
Five by five likelihood and impact risk register

Scope

This assessment covers nursing practice on an adult inpatient ward and the advanced nursing roles that work alongside it, from medicines and clinical observations to documentation, consent, handovers, equipment and escalation. It does not cover medical diagnosis, surgery or any specific employer. Jurisdiction, licensing rules, service size and record systems are not specified and are treated as assumptions for teaching. The scores illustrate method and do not describe a real service.

Context

The ward has registered nurses, healthcare assistants, a clinical nurse lead and two advanced practice nurses who prescribe within agreed protocols and lead discharge planning. Care is recorded in an electronic record with paper back up charts. Medicines are dispensed from a pharmacy-supplied cabinet system, and monitoring equipment is shared across bays. Shifts change twice a day and bed pressure varies. Each risk is scored before controls to show its natural level, then again after existing controls and the additional controls proposed here.

Objectives, assets and stakeholders

The objective is to deliver safe, effective and respectful nursing care, protect patient information, keep staff competent and supported, and stay within the scope of each role. The assets in scope are the patients in care, the medicines and clinical equipment, the electronic and paper records, the staff skills and the reputation of the ward. Stakeholders include patients and families, nurses and healthcare assistants, advanced practice nurses, medical colleagues, pharmacy staff, managers, the professional regulator and the public. Clear roles matter: every risk has one owner role, and the clinical nurse lead reviews this register with the ward manager each month and reports to the clinical governance group.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H06 Likelihood 4, impact 4, score 16, high: H01 Likelihood 4, impact 5, score 20, critical: H02
3 Possible Likelihood 3, impact 3, score 9, medium: H04 Likelihood 3, impact 4, score 12, high: H03 H05
2 Unlikely Likelihood 2, impact 5, score 10, high: H07 H08
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible Likelihood 3, impact 2, score 6, medium: H06
2 Unlikely Likelihood 2, impact 2, score 4, low: H04 Likelihood 2, impact 3, score 6, medium: H01 H03 H05 Likelihood 2, impact 4, score 8, medium: H02 H07
1 Rare Likelihood 1, impact 4, score 4, low: H08
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Medication administration error 16 High 6 Medium Ward manager with pharmacy lead
H02 Missed clinical deterioration during handover 20 Critical 8 Medium Clinical nurse lead
H03 Breach of patient privacy in records and conversations 12 High 6 Medium Information governance lead
H04 Gaps in consent and clinical documentation 9 Medium 4 Low Clinical governance lead
H05 Equipment failure or record system outage 12 High 6 Medium Ward manager
H06 Competence and staffing gaps in advanced roles 12 High 6 Medium Practice development lead
H07 Scope of practice breach by advanced nursing roles 10 High 8 Medium Advanced practice lead
H08 Healthcare-associated infection and exposure 10 High 4 Low Infection prevention lead
H01

Medication administration error

Safety Before 16 After 6

A wrong drug, dose, route, time or patient is given, or a prescribed change is missed at transfer, causing harm to the person receiving care.

Who or what is affected: Patients, nurses, prescribers and pharmacy staff

Causes

High workload, interruptions during medicine rounds, look alike drug names and changes ordered late in the day.

Consequences

Adverse drug reaction, extra treatment, longer stay and possible serious harm.

Existing controls

  • Two identifier checks are completed before each administration.
  • Medicines are stored and dispensed through a pharmacy-supplied cabinet system.

Control gaps

Barcode checks are not used on every ward, and omitted doses are reported only when someone notices them.

Additional controls

  • Prevent: Use barcode checks at the bedside for all high-risk medicines before every dose.
  • Detect: Run a weekly audit of omitted and late doses against the medicine chart.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Ward manager with pharmacy lead Target: Within 30 days Early warning: Two or more omitted or late doses of high-risk medicines recorded in one week.
H02

Missed clinical deterioration during handover

Safety Before 20 After 8

Early warning scores or changes in breathing, consciousness or urine output are not recognized or escalated after a shift change or transfer, so a patient worsens before a medical review.

Who or what is affected: Patients, bedside nurses and medical teams

Causes

Shift changes, unclear ownership of unstable patients and high acuity with low staffing.

Consequences

Cardiac arrest, progression of sepsis, avoidable transfer to intensive care and death.

Existing controls

  • Observations are recorded on a standard early warning chart.
  • A structured handover tool is used at the start of each shift.

Control gaps

The handover tool is used inconsistently, and escalation thresholds are not checked after hours.

Additional controls

  • Prevent: Hold a bedside handover with the patient for every patient with a raised score.
  • Respond: Use a graded escalation call that a nurse can make without waiting for a senior colleague.
Likelihood 4 x impact 5 before; 2 x 4 after Owner: Clinical nurse lead Target: Within 14 days Early warning: Early warning score rising by two or more points without a documented review.
H03

Breach of patient privacy in records and conversations

Technology and data Before 12 After 6

Patient information is viewed without need, left on screens or printed sheets, or discussed where others can hear, breaching confidentiality and trust.

Who or what is affected: Patients, families, staff and visitors

Causes

Shared workstations, busy corridors and curiosity about known patients.

Consequences

Complaint, disciplinary action, loss of trust and possible regulatory referral.

Existing controls

  • Staff sign in with individual accounts that record each access.
  • Screens are locked when staff leave a bay.

Control gaps

Access audits are run only after a complaint has been made.

Additional controls

  • Prevent: Limit record access to the roles and patients each member of staff is assigned to.
  • Detect: Audit a random sample of record access each month and follow up any unexplained access.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Information governance lead Target: Within 60 days Early warning: Record access for a patient with no assigned care in the same shift.
H04

Gaps in consent and clinical documentation

Legal and compliance Before 9 After 4

Consent for a procedure or treatment is not obtained or recorded, or entries are late, unclear or altered, so the care given cannot be shown to have been lawful or safe.

Who or what is affected: Patients, nurses, clinicians and the service

Causes

Urgent procedures, unclear capacity assessments and documentation left until the end of a shift.

Consequences

Complaints, challenge to the validity of consent and weak evidence if care is questioned.

Existing controls

  • A consent form is completed before planned procedures.
  • Entries must be signed with name, role and time.

Control gaps

Consent is recorded on paper while notes are electronic, so the two records can disagree.

Additional controls

  • Prevent: Check consent and capacity notes on the pre-procedure checklist before each procedure.
  • Detect: Review a sample of charts each month for missing or late entries.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinical governance lead Target: Within 45 days Early warning: A procedure recorded with no matching consent entry on the chart.
H05

Equipment failure or record system outage

Operational Before 12 After 6

A pump, monitor, bed alarm or the electronic record fails or runs slowly, so observations, infusions or alerts are delayed or missed.

Who or what is affected: Patients, nurses and support staff

Causes

Ageing devices, unplanned outages, unclear ownership of repairs and equipment shared between bays.

Consequences

Delayed treatment, missed alarms, data loss and a return to paper with transcription errors.

Existing controls

  • Equipment is checked at the start of each shift.
  • Paper charts are kept in each bay as a back up.

Control gaps

Paper back up forms are out of date and are not stocked on every bay.

Additional controls

  • Prevent: Schedule planned servicing and remove faulty equipment from use until it is repaired.
  • Recover: Practice a written downtime procedure and test it at least twice a year.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Ward manager Target: Within 60 days Early warning: Equipment flagged for repair more than once in a month.
H06

Competence and staffing gaps in advanced roles

People Before 12 After 6

Staff work beyond their current competence or without enough cover, or advanced practice nurses cover roles they have not been assessed for, lowering the quality of care.

Who or what is affected: Patients, nurses, healthcare assistants and managers

Causes

Vacancies, sickness, reliance on temporary staff and training that lags behind changes in role.

Consequences

Clinical errors, poor assessment, staff burnout and resignations.

Existing controls

  • Competency sign off is completed for core clinical skills each year.
  • The rota is checked by the ward manager each week.

Control gaps

Competency records are kept by each manager, with no central check against the role.

Additional controls

  • Prevent: Set a minimum skill mix for each shift and pause admissions when it is not met.
  • Detect: Track completed competency assessments against role requirements each quarter.
Likelihood 4 x impact 3 before; 3 x 2 after Owner: Practice development lead Target: Within 90 days Early warning: Shifts that run below the minimum agreed skill mix.
H07

Scope of practice breach by advanced nursing roles

Legal and compliance Before 10 After 8

An advanced practice nurse prescribes, orders tests or makes a clinical decision outside agreed protocols or beyond their authorization, or delegates work to staff who are not trained for it.

Who or what is affected: Patients, advanced practice nurses, medical colleagues and the regulator

Causes

Unclear protocol boundaries, pressure to cover gaps and new roles without a clear role description.

Consequences

Harm from inappropriate treatment, regulatory action and loss of professional standing.

Existing controls

  • A written scope of practice is agreed for each advanced role.
  • Protocols list the medicines and tests that can be ordered.

Control gaps

Protocols are not reviewed when new medicines or tests are approved.

Additional controls

  • Prevent: Check each order against the approved protocol before it is signed.
  • Respond: Stop the activity and refer to a medical lead when a request falls outside scope.
Likelihood 2 x impact 5 before; 2 x 4 after Owner: Advanced practice lead Target: Within 60 days Early warning: Orders placed outside the protocol list during a month.
H08

Healthcare-associated infection and exposure

Safety Before 10 After 4

Hand hygiene is missed, sharps are mishandled or isolation is not applied, so patients or staff acquire an infection or are exposed to blood or body fluids.

Who or what is affected: Patients, nurses, visitors and cleaning staff

Causes

Busy shifts, shared equipment and unclear isolation rules for visitors.

Consequences

Spread of infection, longer stay, needle stick injury and staff absence.

Existing controls

  • Hand hygiene audits are carried out each month.
  • Sharps bins are placed at every bay.

Control gaps

Exposure reports are filed late and are not linked to the ward audit results.

Additional controls

  • Prevent: Provide hand rub at every bed space and a clear isolation sign on the door.
  • Detect: Review infection and exposure reports each week and act on any cluster.
Likelihood 2 x impact 5 before; 1 x 4 after Owner: Infection prevention lead Target: Within 30 days Early warning: Two or more infections on the same bay within a week.

Rating method and evaluation

Each risk is rated on two five-point scales. Likelihood runs from Rare to Almost certain, and impact runs from Negligible to Catastrophic. Multiplying the two gives a score from 1 to 25, which falls into one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. The score is a guide for ordering work, not a measurement. Inherent risk is the score before any controls. Residual risk is the score after the existing and added controls, and it must never be higher than the inherent score. Impact is judged on harm to the patient, the effect on wider care, legal exposure and loss of trust, and a risk to a patient is never rated down only because it has not yet happened. Anything still Critical or High needs senior attention and a dated plan, anything Medium needs routine controls with a named owner, and anything Low is accepted and watched. Nurses and patients should challenge the ratings at huddles and in incident reviews, and every risk is rescored whenever an indicator reaches its threshold.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 6 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
Early warning scores rising by two or more points without a documented review.Escalate to the clinical nurse lead at once when a score rises without review, and to the medical team if the patient is not reviewed within 30 minutes.
Omitted or late doses of high-risk medicines recorded in the weekly audit.Escalate to the ward manager when two or more occur in a week, and to the pharmacy lead if the pattern continues for a month.
Record access for patients with no assigned care in the same shift.Escalate to the information governance lead within one working day, and to the clinical governance lead if the access cannot be explained.
Shifts that run below the minimum agreed skill mix.Escalate to the ward manager before the shift starts, and to the nurse director if admissions must be paused.
Orders placed outside the approved protocol list or infections clustering on one bay.Escalate to the advanced practice lead or infection prevention lead at once, and to the clinical governance group within a week.

Contingency arrangements

If a serious event occurs, such as a patient who deteriorates unexpectedly, a confirmed medication error or a loss of the electronic record, the nurse in charge calls the medical team and follows the escalation pathway. The patient is kept safe first, and the event is reported on the incident system. The ward manager activates the downtime procedure and the paper back up charts. The information governance lead is informed of any possible data loss, and families are told what happened early and plainly. Staff involved receive support, and the review is shared for learning.

Prioritized action plan

  1. Introduce a bedside handover for every patient with a raised early warning score, owner clinical nurse lead, within 14 days.
  2. Use barcode checks for high-risk medicines and review omitted doses weekly, owner ward manager with pharmacy lead, within 30 days.
  3. Check every advanced practice order against the approved protocol before signing, owner advanced practice lead, within 60 days.
  4. Restrict record access by role and start a monthly access audit, owner information governance lead, within 60 days.
  5. Set a minimum skill mix for each shift and track competency assessments centrally, owner practice development lead, within 90 days.

Conclusion

Safe nursing depends on steady habits: structured handovers, checks before every medicine, consent recorded at the time, protected records and clear limits on advanced roles. The highest scores sit with missed deterioration and medication error, and each has actions that bring the residual score down. Treat the register as a living record, review it on the stated cycle, and seek specialist clinical, legal and regulatory advice for any real case or any question beyond the scope of this educational example.

Assumptions and limitations

Assumptions

  • The service is an adult inpatient ward with a named medical team responsible for diagnosis and overall treatment plans.
  • Advanced practice nurses work under written scope of practice documents and approved protocols, which are assumed to exist.
  • Staff hold current registration with the relevant professional body and receive annual training on core clinical skills.

Limitations

  • The scores are examples for learning and do not describe any real ward, service or patient group.
  • Nursing law, prescribing rules, consent requirements and privacy duties differ by jurisdiction and change over time, so specialist review is needed.
  • This is educational content and is not clinical, legal or regulatory advice, and it does not replace a formal site-specific assessment.

Related frameworks to study

  • Hierarchy of controls
  • Three lines model of risk ownership
  • Structured handover and early warning escalation approaches
  • Incident reporting and learning cycle

Healthcare Risk Assessment

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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