Documenting Med Errors- NCLEX

  1. 0
    In my classes I was taught that for medication errors, an incident report should be filed and it should NOT be mentioned in the Medical record.

    In the Kaplan strategy book p.141 Q.30, they state that an incident report should be filed along with documentation of the event in the medical record.

    I'm sure I could find resources that say otherwise to Kaplan.. I have found a lot of grammar/spelling errors in Kaplan's books, so I wonder if this is an error.

    Which is the right answer for the NCLEX because I feel like its a common question they are likely to ask.

    What are your opinions and why?
  2. Poll: Should Med Errors be documented in the MR and in an Incident Report?

    • No, Only in the Incident Report.

      60.00% 3
    • Yes, Both Incident report and Medical Record

      40.00% 2
    5 Votes
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  4. 6 Comments so far...

  5. 4
    The med error itself should be documented in the chart and that the MD was notified and orders if any. NEVER document the incident report itself in the medical record...that is for internal review. Although they can be obtained by subpoena.......it is more difficult. If You mention it in the medical record then it is a part of the medical record.

    "Patient given Lasix not on MAR. Dr. XYZ notified no new orders received." YES

    "Patient given lasix not on MAR. DR.XYZ notified no new orders received...incident report filed." NO!!!
    NRSKarenRN, nursel56, nurse671, and 1 other like this.
  6. 0
    Interesting...I just recall Ive encounter 2 questions on my nclex review about this. The way I understand it is that you shouldn' t document/attach the incident report on the patients chart however you should note that an incident report is completed it in the nurse's note. Hmmm..not so sure that's just what I remember. Please correct me if im wrong.


    Now a dumb question if for instance you gave the wrong med after checking the pt, reporting it to MD and filing an incident report if there was no harm done to pt do you still tell the patient that a wrong med was given to him?? I would assume yes but not to sure.
    Last edit by nurse671 on Jun 5, '12 : Reason: space
  7. 1
    a. Document in chart: "Medication XYZ given, not on Med Record."
    b. Notify the physician,record any orders given. Document: "Notified Dr Love, no new orders given"
    c. Observe patient for side effects "Pt observed afterward x 2 hrs, no problems noted."
    d. Write up incident report separately, submit to Nurse Mgr for review---objectively state facts only, do not place blame. Short, sweet and to the point. Do not mention in incident report in patient chart.
    Last edit by NRSKarenRN on Apr 30, '13
    nurse671 likes this.
  8. 0
    So glad I came upon this. I was called in to the BON for not documenting in the chart that I gave a patient the wrong medication. Furthermore the patient required follow up (it was a BP med) and that was not done either. It seems to me that facilities tell you not to documetn an error and foolishly nurses listen. I just had another nurse recently tell me 'we are not supposed to document errors". I told her that is not what the state would say and that it depended on what the error was. I document errors in a very general manner. I wish health care facilities did not do this. Makes it look like information is being hidden.
  9. 1
    Quote from katherine100
    So glad I came upon this. I was called in to the BON for not documenting in the chart that I gave a patient the wrong medication. Furthermore the patient required follow up (it was a BP med) and that was not done either. It seems to me that facilities tell you not to documetn an error and foolishly nurses listen. I just had another nurse recently tell me 'we are not supposed to document errors". I told her that is not what the state would say and that it depended on what the error was. I document errors in a very general manner. I wish health care facilities did not do this. Makes it look like information is being hidden.
    Don't confuse the two, what you are NOT supposed to do is document that it was an error.

    For example, let's say that the order for the medication was 1 mg of Morphine.

    Let's say you gave 2 mg of Morphine in error.

    You are NOT going to chart that you gave 2mg of Morphine by mistake or even "2 Mg of Morphine given instead of 1 mg"

    You are going to SIMPLY chart the amount you gave, the fact that there was patient follow-up. I have been told to refrain from putting "MD Notified" instead chart "Discussed patient with Dr. Smith, no new orders". (as "MD notified" is a red flag that there was an issue)

    Let the attorney's find the error....don't draw attention to it.

    Referencing "incident report completed" or anything to that nature, is an incorrect answer.
    NRSKarenRN likes this.
  10. 0
    So what if MD notified raises a red flag. If the patient has a right to know then charting 'md notifed' should not be an issue. clearly everyone has their own opinion. The BON says otherwise.


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