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?
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
Jun 5, '12
by NRSKarenRN, BSN, RN Moderator
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