Medication Error Incident Report
I. Incident Description
On May 30, 2050, at approximately 10:00 AM, a medication dispensing error occurred in the Endocrinology Unit at [YOUR COMPANY NAME]. The patient, Mr. Leon Hanson, received a double dose of insulin due to a miscommunication between the nursing staff and the pharmacy. The error was discovered when Mr. Hanson experienced symptoms of hypoglycemia shortly after the administration.
II. Date and Time of Incident
Date: May 30, 2050
Time: 10:00 AM
III. Medication Details
Medication Name | Dosage Prescribed | Dosage Administered | Route |
|---|
Insulin Glargine | 10 units | 20 units | Subcutaneous |
IV. Patient Information
V. Individuals Involved
Name | Role | Responsibility |
|---|
Nurse [YOUR NAME] | Administering Nurse | Administered the medication |
Pharmacist John Brown | Dispensing Pharmacist | Dispensed the medication |
Dr. Emily White | Attending Physician | Ordered the medication |
VI. Type of Error
VII. Consequences
Mr. Hanson exhibited symptoms of hypoglycemia, including sweating, dizziness, and confusion. Immediate action was taken to stabilize his blood glucose levels. He was closely monitored and fully recovered without long-term effects.
VIII. Root Cause Analysis
The root cause of the error was identified as a breakdown in communication during the medication handoff process. The nurse misinterpreted the pharmacist’s instructions, leading to administering a double dose of insulin.
IX. Corrective Actions
Staff Education and Training: Conducted additional training sessions for nursing and pharmacy staff to reinforce proper communication protocols during medication handoff.
Policy Review and Update: Updated the medication administration policy to include a double-check system where another nurse or pharmacist verifies the dosage before administration.
Implementation of Technology Solutions: Introduced electronic medication administration records (eMAR) to reduce the likelihood of human error.
X. Signatures
Prepared by:
Nurse [YOUR NAME]
Date: May 31, 2050
Reviewed by:
Dr. Emily White
Date: May 31, 2050
Approved by:
[YOUR COMPANY NAME] Risk Manager
Date: June 1, 2050
Organization: [YOUR COMPANY NAME]
Address: [YOUR COMPANY ADDRESS]
Contact Number: [YOUR COMPANY NUMBER]
Website: [YOUR COMPANY WEBSITE]
Email: [YOUR COMPANY EMAIL]
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