A nurse discovers that a medication error occurred during the previous shift but was not documented. The patient received double the prescribed dose of a cardiac medication and experienced mild hypotension that resolved without intervention. What is the most appropriate action for the nurse to take?

Upon discovering a medication error, the nurse's first priority is always patient assessment and stabilization. In this scenario, the patient experienced mild, self-resolving hypotension. Even when no intervention is required, the nurse must monitor the patient closely for any delayed effects and document all assessment findings.

The correct action involves two separate, essential processes:

1. Patient's Medical Record: Document the error factually, including the medication given, the actual dose, the patient's response, and any monitoring performed. Do not reference the incident report in the chart. This creates a legal record of the event.
2. Incident (Occurrence) Report: Complete this confidential report per facility policy. Its purpose is risk management and quality improvement, not punishment. It allows the system to analyze the root cause and prevent recurrence.

• Accountability: The discovering nurse is responsible for initiating the report, regardless of when the error occurred.
• No Blame Culture: Incident reports are designed to foster a just culture focused on system fixes, not individual blame.
• Timeliness: File the incident report as soon as patient safety is assured to ensure accurate recall of details.

Do not rely solely on a verbal handoff to the charge nurse. Do not delay documentation to consult the previous shift nurse first, as this postpones the formal safety review. Do not document the filing of an incident report in the patient's chart, as this could compromise its protected, confidential status.