Incident Report for Medication Error

On April 12, 2024, at approximately 10:15 AM, a medication error incident occurred at Springfield General Hospital, located at 123 Healthway Drive, Springfield, SG. The incident involved the administration of 10 mg of Medication X instead of the prescribed 5 mg to Patient John Doe, a 58-year-old male admitted for treatment of chronic heart disease.

The error was identified by Nurse Jane Smith during a routine check of patient medication records against administered dosages. Upon discovering the discrepancy, Nurse Smith immediately informed the attending physician, Dr. Lisa Ray, and the hospital’s pharmacy department.

Patient Doe was under continuous monitoring for any adverse effects due to the medication error. Fortunately, the patient exhibited no immediate signs of distress or negative reaction to the higher dosage. Dr. Ray ordered additional tests, including blood work and cardiac monitoring, to ensure the patient’s safety and well-being.

An investigation into the incident revealed that the error originated from a misinterpretation of the medication order, which was handwritten and partially illegible. The nursing staff mistook the dosage due to the unclear handwriting, leading to the administration of a higher dose.

In response to this incident, the following corrective actions have been implemented:

Immediate reevaluation of all current handwritten medication orders for clarity and accuracy.
Mandatory retraining for all hospital staff on medication administration protocols and the importance of double-checking orders with pharmacy and attending physicians.
Introduction of a policy requiring electronic entry of all medication orders to avoid issues related to illegibility.
Patient Doe was informed of the medication error and the steps taken to address it. He was understanding and appreciative of the transparency and the measures implemented to ensure his safety. The hospital has apologized to the patient and his family and has waived all charges related to the additional tests conducted as a result of the error.

This incident has been documented in the hospital’s incident reporting system for review and analysis. Springfield General Hospital is committed to maintaining the highest standards of patient care and safety and will continue to evaluate and improve its medication administration processes to prevent future errors.