A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?
Explanation & Rationale
Choice A Reason: Incident report is correct .When a medication error occurs, it should be documented in an incident report. An incident report is a formal record of an event that compromises client safety, such as a medication error. It allows the healthcare facility to investigate the error, take corrective actions, and implement preventive measures to improve patient safety. Incident reports are generally kept separate from the client's medical record to protect the confidentiality of the investigation. Choice B Reason: Controlled substance inventory record is incorrect. This record is used to track the administration and wastage of controlled substances and is not the appropriate place to document a medication error. Choice C Reason: Provider's progress notes is incorrect. The provider's progress notes are used for documenting the client's medical history, physical examination, diagnosis, treatment plan, and progress. It is not the place to document medication errors. Choice D Reason: Nursing care plan is incorrect. The nursing care plan outlines the client's nursing diagnoses, goals, interventions, and outcomes. It is not the appropriate place to document medication errors.