A nurse gives an incorrect medication to a patient without doing all of the mandatory checks, but the patient has no ill effects from the medication. What actions should the nurse take after reassessing the patient? (Select all that apply.)
a. Notify the health care provider of the situation.
b. Document in the patient's medical record that an occurrence report was filed.
c. Document in the patient's medical record why the omission occurred.
d. Discuss what happened with all of the other nurses and staff on the unit.
e. Continue to monitor the patient for any untoward effects from the medication.
f. Send an occurrence report to risk management after completing it.
A, E, F
Examples of an occurrence include an error in technique or procedure such as failing to properly identify a patient. Institutions generally have specific guidelines to direct health care providers how to complete the occurrence report. The report is confidential and separate from the medical record. The nurse is responsible for providing information in the medical record about the occurrence. It is also best for the nurse to discuss the occurrence with nursing management only. The risk management department of the institution also requires complete documentation. The fact that an occurrence report was completed is not documented in the patient's medical record. No discussion of why the omission in procedure occurred should be documented in the patient's medical record. Errors should be discussed only with those who need to know such as the health care provider, appropriate administrative personnel, and risk management.
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