The literature indicates that drain monitoring is a frequently undervalued aspect of patient care, and that the drain care provided is often inconsistent and inadequate. There are numerous potential implications of suboptimal drain care for patients, nurses, teams and healthcare organisations. Since acute care is increasingly being delivered in the community, there is a greater need for nurses to have an understanding of effective drain care. This article describes the rationale for drain insertion and its associated complications. It uses a case study to illustrate how suboptimal drain monitoring and documentation can negatively affect patient care and safety. This article also discusses several important issues raised in the case study, such as suboptimal documentation, and how these may have consequences for nurses, teams and healthcare organisations. Recognition of these elements supports initiatives that nurses could apply to practice to reduce the occurrence of similar incidents.