Documentation Error Form Medication Reporting
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therapy or failing to receive it as prescribed or intended. Medication errors happen for many reasons. However, failing to follow the six rights of medication administration is probably the most basic cause. medication error reporting form (pdf) Whether or not the patient was harmed or had an adverse reaction as medication error report form template a result of the error, all medication errors must be reported, not only for patient safety but for quality-improvement reporting pharmacy errors purposes. When you or a colleague makes a medication error, the patient’s safety and well-being are your first priority. Monitor the patient closely and notify the provider and your nurse manager as how to document medication error in medical record soon as possible. Once the patient is stable, the person who made the error must complete an incident, variance, or quality-assurance report as soon as possible, but generally within 24 hours of the incident. The report should include the following information and any additional information required by facility policy: patient information, the location and time of the incident, a description of what happened and what
Medication Error What To Do After
was done about it, the condition of the patient, and the nurse’s signature. The incident report does not become a permanent part of the patient’s medical record; do not mention it in your documentation on the patient’s chart. The intent of this is not to hide the fact that an error occurred, but to protect the nurse and the facility. Depending on the error that occurred and the outcome, the facility may be required to report the incident to the Joint Commission. Nurses should feel comfortable reporting a medication error and not fear disciplinary action. Incident reports should not be used for disciplinary purposes but to improve systems and processes. Managers who use incident reports for disciplinary purposes run the risk of increased failure to report errors and of the same mistakes being made again and again. Medication incident report form References Bentz, P. M., & Ellis, J. R. (2007). Modules for basic nursing skills (7th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 828. Duell, D. J., Martin, B. C., & Smith, S. F. (2004). Clinical nursing skills: Basic to advanced skills (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc. pp. 518-519.