A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A. A nurse discovers that a client's family member has administered a PCA dose: Unauthorized administration of medication by a family member constitutes a medication error and breach of safety protocols, requiring an incident report to document the event and prevent future occurrences. B. A nurse observes a client vomiting after receiving an oral pain medication: Vomiting can be an expected side effect of medications. While it should be documented in the medical record, it does not typically require an incident report unless it results in harm or deviates from standard care. C. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client: Over-infusion of fluids is a serious medication/therapy error with potential for harm. An incident report is necessary to document the error, ensure client safety, and support system improvements. D. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: Proper restraint removal is part of standard care and does not constitute an incident.