RN Nursing · Medication Errors and Safe Practices · Practice question
A nurse is preparing to complete an Incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)
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Identify the medication name and dosage administered to the client in the report.
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Place a copy of the completed report in the client's medical record.
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Include the time the medication error occurred in the report.
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Make a copy of the incident report for personal record keeping.
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Obtain an order from the client's provider to complete the report.
Answer & explanation
Correct: Identify the medication name and dosage administered to the client in the report. · Include the time the medication error occurred in the report.
An incident report is a formal quality-improvement document used to record unexpected events such as medication errors. The nurse should identify the medication name and dosage administered in the report because this information is essential for understanding the nature and potential impact of the error and for initiating appropriate follow-up. Including the time the medication error occurred is equally important because it helps reconstruct the sequence of events and supports timely assessment of any adverse effects on the client. Placing a copy of the completed incident report in the client's medical record is incorrect — incident reports are internal risk-management documents and should never be filed in the medical record, as this could expose the institution to legal liability and improperly influence the medical narrative. Making a personal copy of the incident report is also inappropriate and potentially a breach of confidentiality and organizational policy. Obtaining a provider order to complete an incident report is not required; the nurse has an independent obligation to complete the report when an error occurs, and it is not contingent on a physician's order. The primary purpose of an incident report is to document the facts objectively so the organization can analyze the event and implement preventive measures.
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