Incident Report Writing in Hospital Example [Edit & Download]

Header Information
Date: February 12, 2025
Time: 3:15 PM
Location: Emergency Department, City General Hospital
Reported by: Lisa Thompson, RN, Emergency Department

Description of the Incident
At approximately 3:00 PM, a medication error occurred in the Emergency Department of City General Hospital. The incident involved the accidental administration of a higher dosage of Morphine to patient Jane Doe, who was admitted for severe abdominal pain. The prescribed dosage was 2 mg IV, but the patient received 5 mg IV due to a miscommunication between the nursing staff during a shift change.

Parties Involved

• Jane Doe: Patient, recipient of the incorrect medication dosage.
• Nancy Clark: RN, administered the medication.
• Robert Wells: RN, responsible for overseeing the medication handover.
• Dr. Emily Stanton: Attending Physician, prescribed the correct dosage.

Actions Taken
Upon realization of the error, the following steps were immediately taken:

• The patient was monitored closely for any adverse effects from the overdose.
• Vital signs were checked every 5 minutes, and oxygen saturation was continuously monitored.
• Dr. Emily Stanton was notified, and additional medication to counteract the effects of Morphine was administered.
• A detailed review of the patient’s medical chart and medication administration record was conducted to understand the error’s origin.
• The patient and her family were informed about the incident, and apologies were extended.

Recommendations for Future Prevention

1. Enhanced Communication Protocols: Implement standardized communication protocols during shift changes, specifically regarding patient care and medication details.
2. Regular Training on Medication Safety: Mandatory training sessions for all medical staff on safe medication administration practices and error prevention.
3. Double-Checking Mechanism: Introduce a mandatory double-check system for all medication dosages administered in critical care areas.
4. Use of Medication Administration Technology: Increase the use of barcode scanning for medication administration to ensure the correct patient, drug, dosage, and time.
5. Audit and Feedback: Regular audits of medication administration practices and feedback sessions with staff to reinforce adherence to safety protocols.

Attachments

• Patient Monitoring Records: Documenting the patient’s vital signs and condition post-incident.
• Staff Statements: Written accounts from Nancy Clark and Robert Wells detailing their roles and perspectives on how the incident occurred.
• Medication Administration Record Review: Analysis of the medication administration process and identification of the failure point.
• Incident Review Meeting Minutes: Notes from the meeting held with the hospital safety committee to discuss the incident and preventive measures.