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    Ati Rn pharmacology proctored exam 2023

    A nurse is preparing to administer a dose of ampicillin to a client. The nurse scans the medication and the client's identification band and realizes the client has a penicillin allergy. Which of the following should the nurse use to document the incident?

    Explanation & Rationale

    A. Medication reconciliation report: A medication reconciliation report is used to compare the client’s current medications with new prescriptions to prevent errors during transitions of care. It is not used to document incidents or near misses. B. Root cause analysis form: A root cause analysis is a detailed process performed after a serious adverse event to determine underlying system issues. It is not the initial documentation tool for a single medication error or near-miss. C. Plan of care: The plan of care outlines nursing interventions and goals for the client’s treatment. It is not used to record or report medication-related incidents. D. Occurrence report: An occurrence (incident) report is the appropriate document for recording medication errors or near misses, such as discovering an allergy before administration. It provides information for quality improvement and risk management without becoming part of the client’s medical record.

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