Hospital Medication Error Report

On July 15, 2024, at approximately 10:30 AM, a medication error occurred in the General Ward of Mercy General Hospital, located at 123 Healing Way, Harmony Town, HT. The incident involved the administration of 10mg of Medication X, intended for Patient John Doe, to Patient Jane Smith due to a misinterpretation of the medication chart by the attending nurse, Nurse A. Smith.

The error was identified approximately 30 minutes post-administration when Nurse B. Jones, preparing to administer another medication to Patient Smith, noticed the discrepancy between the medication chart and the medications logged as given. Immediate action was taken to assess Patient Smith’s condition, which fortunately showed no adverse reactions to the unintended medication.

Dr. C. Miller, the attending physician, was notified of the incident and evaluated Patient Smith. As a precautionary measure, Patient Smith was placed under close observation for the next 24 hours to monitor for any delayed adverse effects. The hospital’s pharmacy department conducted a review of the medication storage and dispensing procedures to identify any contributory factors to the error.

A root cause analysis was conducted, revealing that the primary factor contributing to the incident was the similarity in packaging and labeling between Medication X and Medication Y, which was intended for Patient Smith. Additionally, it was identified that the medication chart placement on the patients’ beds was not consistent, leading to potential confusion.

Corrective actions taken in response to the incident include retraining of nursing staff on medication administration protocols, introduction of a double-check system for medication administration, and consultation with the pharmacy department to address medication labeling and storage concerns. Furthermore, the hospital has implemented a standardized procedure for the placement of medication charts to prevent similar incidents in the future.

Patient Smith and her family were informed of the incident and the measures taken to ensure her safety. They were also assured of the hospital’s commitment to preventing such errors in the future. An incident report was filed with the hospital’s risk management department, and a case review meeting has been scheduled to discuss the incident and the hospital’s response in detail.