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. Plan of care: The plan of care is a document that outlines the client’s treatment plan and goals, not a place to report medication errors or incidents. It is not used to document adverse events like a medication allergy response. B. Occurrence report: An occurrence report (also called an incident report) is the appropriate document for reporting any unusual event, including medication errors, adverse reactions, or near misses. This report helps track and address errors or issues to improve patient safety. C. Medication reconciliation report: A medication reconciliation report is used to compare the client’s current medications with those ordered during admission or transition of care. It is not used to report an allergic reaction or medication incident. D. Root cause analysis form: Root cause analysis is used after a serious incident to identify underlying causes and prevent future occurrences. While it’s important for systemic issues, it is not used for documenting a single incident, such as this scenario involving an allergic reaction.