What is the 4 eyes assessment in nursing? A comprehensive guide

September 29, 2025 •

3 min read

According to the Agency for Healthcare Research and Quality (AHRQ), tens of thousands of hospital patients die each year from pressure injuries. To combat this, hospitals are implementing patient safety protocols such as the 4 eyes assessment in nursing, a dual-nurse skin examination to identify and prevent hospital-acquired pressure injuries (HAPIs).

Quick Summary

The 4 eyes assessment is a patient safety protocol that involves two nurses conducting a head-to-toe skin examination of a patient upon admission or transfer. Its primary purpose is to accurately identify existing pressure injuries and proactively implement interventions to prevent new ones from developing, thereby reducing hospital-acquired pressure injuries.

Key Points

Dual-Nurse Examination: The 4 eyes assessment involves two nurses performing a comprehensive head-to-toe skin check on a patient upon admission or transfer.
Pressure Injury Prevention: The primary goal is to identify existing pressure injuries early to prevent new ones and reduce hospital-acquired pressure injuries (HAPIs).
Collaborative Safety: The process promotes shared accountability, peer verification, and enhanced accuracy, reducing the risk of human error.
'Four Eyes in Four Hours': A common protocol dictates the assessment must be completed within four hours of the patient's arrival on the unit.
Improved Outcomes: By catching skin integrity issues early, the protocol leads to better patient outcomes and reduces the financial burden on healthcare facilities.
Documentation Importance: Co-signing the assessment in the electronic medical record ensures proper documentation and accountability from both nurses involved.

Understanding the 4 Eyes Assessment in Nursing

The 4 eyes assessment is a quality improvement initiative designed to enhance patient safety by ensuring a more thorough and accurate skin assessment. The name derives from the involvement of two nurses—hence, four eyes—in the examination process. This collaborative approach is a critical step in a hospital's broader pressure injury prevention program, aiming to catch subtle skin abnormalities that a single nurse might overlook.

The 'Four Eyes in Four Hours' Protocol

A common implementation of this protocol is known as "Four Eyes in Four Hours" (4E4H). This specific guideline requires two registered nurses to perform a comprehensive head-to-toe skin assessment on each patient within four hours of their admission to or transfer within a unit. The time-sensitive nature of the protocol is crucial for establishing an accurate baseline of the patient's skin condition early in their hospital stay.

The Step-by-Step Assessment Process

The 4 eyes assessment follows a structured procedure to ensure consistency and thoroughness:

Patient and Witness Recruitment: The primary nurse recruits another registered nurse to perform the assessment. In some cases, depending on institutional policy, a licensed practical nurse (LPN) or patient care assistant (PCA) may serve as the second witness.
Privacy and Consent: The nurses ensure patient privacy by closing the door and curtains. They then explain the purpose of the assessment to the patient, obtain consent, and address any questions or concerns.
Head-to-Toe Examination: The two nurses work together to meticulously examine the patient's entire skin surface. This includes checking bony prominences, skin folds, and hard-to-see areas like the back of the head and heels.
Identification of Abnormalities: Both nurses actively look for signs of pressure injuries, such as non-blanchable redness, blisters, or open areas.
Electronic Documentation and Co-signing: The findings are documented in the electronic medical record (EMR). Critically, both nurses sign off on the assessment, confirming their participation and agreement on the findings.
Intervention Implementation: If a pressure injury is identified, interventions are promptly initiated. This might include repositioning schedules, specialized mattresses, or a consultation with a wound care nurse.

Why a Dual-Nurse Assessment is Necessary

The dual-nurse approach significantly improves the reliability and quality of the assessment. The principle behind it is similar to the financial "four-eyes principle," which requires two people to approve critical transactions to prevent errors. In a clinical setting, this translates to:

Increased Accuracy: Two sets of eyes are more likely to notice subtle signs of skin breakdown than one, especially under challenging lighting or with difficult-to-position patients.
Shared Responsibility: The shared accountability between the two nurses reinforces the importance of the task and promotes a culture of safety.
Error Reduction: The peer-review process minimizes the risk of human error or oversight in the initial assessment.
Enhanced Education: The process provides an opportunity for peer-to-peer education, especially when senior nurses are paired with less experienced ones.

Comparison: Single vs. Dual Nurse Skin Assessment


Feature	Single Nurse Assessment	Dual-Nurse (4 Eyes) Assessment
Accuracy	Prone to human error or oversight due to single perspective.	Higher accuracy and reliability from a collaborative review.
Verification	No external verification; relies on one nurse's judgment.	Built-in peer verification and shared accountability.
Documentation	Single signature; less robust from a quality perspective.	Co-signed documentation strengthens medical-legal record.
Pressure Injury Identification	Higher risk of missing subtle or early-stage injuries.	Lower risk of missed injuries; earlier intervention possible.
Implementation	Generally faster for individual assessment.	Requires coordination but saves time and resources long-term by preventing complications.
Education	Limited to self-reflection and training.	Provides a valuable opportunity for peer education and mentorship.

Conclusion

The 4 eyes assessment in nursing represents a best practice standard for preventing hospital-acquired pressure injuries. By implementing a standardized, dual-nurse skin examination protocol, healthcare institutions can significantly increase the accuracy of their assessments, reduce the incidence of preventable complications, and ultimately enhance patient safety and outcomes. The commitment to this collaborative process is a testament to the ongoing evolution of nursing care and the dedication to providing the highest quality of patient-centered treatment. To further explore evidence-based strategies for preventing pressure injuries, visit the Agency for Healthcare Research and Quality.

Frequently Asked Questions

The 4 eyes assessment is a patient safety practice in nursing where two nurses conduct a head-to-toe skin examination of a patient, most often upon admission or transfer, to proactively identify and prevent pressure injuries.

The purpose is to improve the accuracy of skin assessments, reduce the risk of missed or misdiagnosed pressure injuries, and enable prompt intervention to prevent hospital-acquired pressure injuries (HAPIs).

Many healthcare facilities have implemented the 4 eyes assessment as a standard protocol for all new admissions and transfers to ensure a consistent baseline skin assessment for every patient, though specific requirements may vary by institution.

If a pressure injury is identified, the nurses document its stage and location, and immediately initiate appropriate interventions, which may include special equipment, repositioning schedules, and consulting a wound care specialist.

A dual-nurse assessment offers multiple benefits, including increased accuracy, reduced human error, shared responsibility among staff, and enhanced peer education, all of which contribute to better patient outcomes.

The time required for the assessment can vary depending on the patient's condition and mobility, but the "Four Eyes in Four Hours" protocol emphasizes its completion within four hours of arrival to the unit.

In cases of disagreement, hospital policy typically outlines a process for resolving the discrepancy, which may involve a third opinion from a more senior nurse or a wound care nurse to ensure the most accurate documentation and plan of care.