A patient was mistakenly given 40 mg of propranolol (Inderal) instead of her scheduled levothyroxine (Synthroid). After assessing the patient and reporting this to the physician, the nurse makes a written report that a medication was given in error to the patient due to a mixup in
•The report is made to Risk Prevention, a part of hospital management responsible for investigating the root causes of potential or actual errors or patient injuries.
•The goal of root causes analysis is to identify the factors that lead to an error (ex: miscommunications, overstaffing, lack of staff education, need for extra check systems) rather than to place blame on an individual.
•This report should not be included in the patient's MAR or medical record. Only a factual statement about the drug that was given, the effect, and any further physician orders are noted in the patient's chart, never a statement about an error being made.
•The report does not go to the charge nurse.