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1.docx MED ERROR

The document details a medication error incident where a patient received the wrong medication due to unclear prescription caused by illegible handwriting. It identifies human error as the root cause and outlines corrective actions, including immediate medication review and chart verification. Preventive measures proposed include standardizing the prescription process, training on medication safety, and implementing a double-check protocol for high-risk medications.

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pratima
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45 views2 pages

1.docx MED ERROR

The document details a medication error incident where a patient received the wrong medication due to unclear prescription caused by illegible handwriting. It identifies human error as the root cause and outlines corrective actions, including immediate medication review and chart verification. Preventive measures proposed include standardizing the prescription process, training on medication safety, and implementing a double-check protocol for high-risk medications.

Uploaded by

pratima
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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1. Medication Error Incident

Incident Description:

 Incident Type: Medication Error

 Date of Incident: [DD/MM/YYYY]

 Location: [e.g., Ward, ICU]

 Details of the Incident:

o Patient was administered the wrong medication or incorrect dose.

o This caused [e.g., adverse effects like allergic reaction, deterioration of patient
condition, or no effect].

 Outcome/Impact:

o [Describe the outcome, e.g., patient harm, increased treatment costs, delayed
recovery].

Why-Why Analysis for Medication Error

Why 1: Why was the wrong medication administered?

 The prescription was unclear.

Why 2: Why was the prescription unclear?

 The handwriting was illegible.

Why 3: Why was the handwriting illegible?

 The prescriber was in a rush and did not follow standard practices for clear prescription
writing.

Root Cause Identified:

 Human Error: The prescriber did not follow proper protocols for clear and legible
prescription writing, leading to confusion and medication errors.

Corrective Actions (CAPA)

Corrective Action 1: Immediate Medication Review and Patient Safety

 Action: Immediately review all medication orders for the patient and ensure proper
medications are administered. Provide any necessary antidotes or treatment.

 Responsible Person(s): Attending Physician, Nursing Staff

 Timeline: As soon as the error is identified.


 Verification: Monitor patient for adverse effects and confirm the correct medication was
administered.

Corrective Action 2: Review Medication Chart

 Action: Review all medication orders for the past 24 hours and ensure that similar errors
have not occurred.

 Responsible Person(s): Pharmacy Department, Nursing Supervisor

 Timeline: Within 1 hour of the incident.

 Verification: Confirm medication records are corrected and clarified.

Preventive Actions (CAPA)

Preventive Action 1: Standardize Prescription Process

 Action: Implement electronic prescription systems (e-prescribing) to reduce the chances of


illegible handwriting and reduce human errors in prescribing medications.

 Responsible Person(s): IT Department, Medical Director

 Timeline: Within [X] months.

 Verification: Monitor system usage and conduct training sessions.

Preventive Action 2: Training on Medication Safety

 Action: Conduct regular training sessions on safe medication practices for all medical staff to
ensure they understand how to avoid medication errors, including legibility and accurate
documentation.

 Responsible Person(s): Training Department, Medical Director

 Timeline: Ongoing; schedule quarterly refresher courses.

 Verification: Monitor attendance, review training effectiveness via staff feedback.

Preventive Action 3: Double-Check Protocol for High-Risk Medications

 Action: Establish a double-check protocol for high-risk medications, where two staff
members verify the medication and dosage before administration.

 Responsible Person(s): Nursing Supervisor, Pharmacy

 Timeline: Within [X] weeks.

 Verification: Audit compliance with this protocol and verify through incident tracking.

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