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Lessons · Nursing · after a medication error

After a medication error: the order of the next few minutes

Check the patient first, tell the nurse in charge and then the prescriber, document in the record exactly what was given and when, complete the incident report the organisation requires, and keep monitoring as instructed.

Hone is a place to practise a career, one idea a day. This is one of its lessons, written out in full and free to read without an account.

What it is for

Errors happen to careful people on busy shifts, and what happens next decides whether the patient is safe and whether the unit learns anything. The patient comes before the paperwork, and the paperwork comes before going home.

How to think about it

Stay with the patient and check them. Report up, immediately and plainly: the nurse in charge, then the prescriber, with what was given, how much, by what route and at what time. Write the facts in the record. Complete the incident report separately: the record says what happened to the patient, the report is how the organisation learns.

Worked example

1. Check the patient and stay with them
Before any call, any form, any conversation.
2. Tell the nurse in charge
Immediately, and plainly.
3. Tell the prescriber what was given, how much, by what route and when
The facts they need to decide what happens next.
4. Document in the record what was actually given, and at what time
The record follows the patient, so it holds what happened to them.
5. Complete the incident report the organisation requires
A separate document, for the organisation, not a note in the chart.
6. Keep monitoring and recording as instructed
The follow-up is part of the response, not an afterthought.

Your turn

Write who is checked before any call is made.

1. Check the  and stay with them

The trap

Waiting to see whether anything happens before reporting. The minutes between the error and the call are the minutes in which something could have been done, and a late report helps nobody, least of all the person who made the error.

Practise after a medication error on HoneA question on it now, a coding challenge where there is one, and it is remembered for review. Free, no email needed.