A nurse discovers that a medication error occurred during the previous shift but was not documented. The patient experienced no adverse effects. What is the most appropriate action for the nurse to take?
1Document the error in the patient's medical record immediately without notifying anyone else
2Report the incident through the facility's incident reporting system and notify the attending physician✓ 정답
3Ignore the error since the patient experienced no harm and it occurred on a previous shift
4Discuss the error only with the nurse who made the mistake to avoid involving administration
해설
Medication errors must be reported through proper channels regardless of patient outcome to ensure patient safety, legal compliance, and quality improvement. Other options fail to meet legal/ethical reporting obligations.
Clinical Judgment
The core of this issue is making the right decision between patient safety and professional responsibility. Even if no immediate harm came to the patient, a medication error is an indicator of potential risk and systemic flaws. The most appropriate action is to transparently report through the official reporting channel and share the necessary information for patient care with the attending physician. This 1) enables additional monitoring for patient safety, 2) provides data for the institution's quality improvement (QI) activities, and 3) protects the nurse and related medical staff from legal risk. Reporting in a "Just Culture" is for learning and system improvement, not punishment.
Memory Tip:
Remember the RND order: Report, Notify, Document. First, Report to the institutional system, then Notify the attending physician, and finally Document appropriately. The mindset that "there is no harmless error" is important.
KR vs US:
While medication error reporting is also emphasized in Korea, the US NGN/CJMM views this as a core element of Clinical Judgment and strongly emphasizes the personal/professional responsibility of the 'discovering nurse' and their role as an Advocate for the system. Even if there is a culture of reluctance to report, on the exam, official reporting and notifying the physician is always the top-priority correct answer.
Clinical Practice Guide
1. An Incident Report is not a legal document but an internal quality control document. This report is not included in the patient's medical record.
2. In the patient's medical record, make fact-based, objective entries. Example: "0800 Blood pressure 120/80, pulse 72, respiration 16. Patient reports no discomfort. Notified Dr. Smith." (Do not record the fact that an incident report was filed).
3. After notifying the attending physician, the frequency of drug level monitoring or vital sign checks may be adjusted as needed.
Caution:
In SATA (Select All That Apply) questions, the option "No need to report because no harm came to the patient" can never be the correct answer. Also, the option "Only discuss with the colleague who made the error" is considered uncooperative behavior and a violation of reporting duty, making it an incorrect answer.
Medication Error — A preventable event that occurs during the medication process (prescribing, transcribing, dispensing, administration, monitoring) and could cause or has caused harm to the patient.
Incident Report (Occurrence Report) — An internal reporting system within a healthcare facility that formally documents unexpected or undesirable events (such as falls or medication errors). Its purpose is to analyze causes and improve systems rather than to assign blame.
Just Culture — An organizational culture that focuses on finding and improving system flaws rather than blaming an individual for a mistake. It responds by distinguishing between intentional violations, negligence, and system errors.
Quality Improvement — Systematic activities to continuously improve the quality and safety of healthcare services. Incident report data serves as important input for QI activities.
Duty to Report — Legal and ethical duty imposed on healthcare professionals, including nurses, to report errors or incidents that may affect patient safety to appropriate authorities or systems.