A nurse administers the wrong dose of an anticoagulant to a client due to a transcription error, resulting in no adverse effect to the client. What is the nurse's most appropriate first action?
- AComplete an incident report and place it in the client's medical record
- BInform the client's family and wait to see if any symptoms develop before reporting
- CNotify the physician, assess the client, and complete an incident report separate from the medical record
- DDocument the error in the nurses' notes and monitor the client closely
Show answer & explanationAnswer & explanation
Correct answer: C. Notify the physician, assess the client, and complete an incident report separate from the medical record
After a medication error, the nurse's priority is client safety: assess the client and notify the physician immediately, then complete an incident/occurrence report as a separate quality-improvement document that is NOT placed in the medical record. This protects the client and supports systems-level error prevention without exposing the report to legal discovery as part of the chart.
Why the other options are wrong
- A. Incident reports must never be placed in or referenced in the medical record.
- B. Delaying notification and reporting risks client safety and violates timely reporting standards.
- D. Documenting only in nurses' notes without notifying the physician delays needed intervention.
Medication Error Reporting
After a medication error, the nurse must assess the client, notify the physician, document the error and client response in the medical record, and complete a separate confidential incident report for quality improvement purposes.
- Incident reports are never filed in or referenced within the medical record
- Client assessment and physician notification come first
- Incident reports support systems improvement, not punitive action
Memory trick: Assess, notify, chart the facts, report separately