Free Patient Medical Incident Report Template
Patient Medical Incident Report
Incident Report Date: May 28, 2050
I. Incident Details
Incident Date and Time: May 27, 2050, 3:45 PM
Location of Incident: Room 205, Intensive Care Unit (ICU)
Type of Incident: Medication Error
Patient Name: [Patient's Name]
Patient Identification Number: 123456789
II. Incident Description
Description of Incident:
During the patient's routine medication administration, it was discovered that [Patient's Name] received 20 units of insulin instead of the prescribed 10 units. The error occurred due to a miscommunication during the shift change. The patient experienced symptoms of hypoglycemia, including sweating, dizziness, and confusion.
Actions Taken Immediately:
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Administered 15 grams of oral glucose.
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Monitored blood glucose levels every 15 minutes.
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Notified the on-call physician, Dr. [Doctor's Name].
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Documented the incident in the patient’s medical record.
III. Witness Information
Witness 1: [Name]
Contact Information: [Phone Number]
Witness 2: [Name]
Contact Information: [Phone Number]
IV. Medical Treatment Provided
Initial Assessment:
Patient was found to be hypoglycemic with a blood glucose level of 45 mg/dL. Patient was conscious but exhibiting signs of confusion and weakness.
Medical Personnel Involved:
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Dr. [Doctor's Name], On-call Physician
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[Your Name], Registered Nurse
Treatment Administered:
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Administered oral glucose (15 grams).
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Blood glucose levels monitored every 15 minutes until levels stabilized above 70 mg/dL.
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Continuous monitoring for 2 hours post-incident.
V. Follow-Up Actions
Recommendations for Future Prevention:
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Reinforce double-checking protocols for medication administration.
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Implement a mandatory sign-off process for high-risk medications.
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Conduct additional training sessions on effective communication during shift changes.
Follow-Up Care Instructions:
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Continue to monitor blood glucose levels every 4 hours for the next 24 hours.
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Schedule a follow-up appointment with the primary care physician.
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Educate the patient and family members about signs of hypoglycemia and appropriate actions to take.
VI. Reporter Information
Reporter Name: [Your Name]
Reporter Title: Registered Nurse
Contact Information: [Your Email]
VII. Organization Information
Organization Name: [Your Company Name]
Organization Address: [Your Company Address]
Organization Contact Number: [Your Company Number]
Website: [Your Company Website]
Date: May 28, 2050
