Clinical Incident Report

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I. Incident Details

Date	Time	Location
June 1, 2050	2:30 PM	[YOUR COMPANY NAME], Medical Ward 4B

II. Description of Incident

On June 1, 2050, at approximately 2:30 PM, Patient George Simon was administered 500mg of Amoxicillin. Shortly after administration, the patient exhibited signs of an allergic reaction, including hives and difficulty breathing. The patient has a documented allergy to Penicillin, which was clearly noted in his medical chart.

III. People Involved

Name	Role	Contact Information
[YOUR NAME]	Nurse	[YOUR EMAIL]
Dr. Mark Lee	Attending Physician	[YOUR COMPANY EMAIL]
George Simon	Patient	[email protected]

IV. Immediate Actions Taken

Upon noticing the allergic reaction, the following actions were taken:

1. The administration of Amoxicillin was immediately stopped.

2. The patient was given an injection of Epinephrine to counteract the allergic reaction.

3. Dr. Mark Lee was notified and provided immediate medical attention.

4. The patient was monitored closely for any further adverse reactions.

5. The incident was reported to the hospital's quality and risk management team.

V. Root Cause Analysis

A thorough review of the incident revealed the following contributing factors:

• The medication order was entered incorrectly into the electronic health record (EHR) system.

• The nurse administering the medication did not cross-check the patient's allergy information in the EHR before administration.

VI. Recommendations

To prevent similar incidents in the future, the following recommendations are made:

• EHR System Alerts: Implement an automatic alert system in the EHR that flags any medication orders containing allergens listed in the patient's chart.

• Double-Check Protocols: Enforce a mandatory double-check procedure for all medication administrations, especially for patients with known allergies.

• Staff Training: Conduct regular training sessions for all healthcare staff on the importance of verifying allergy information before administering any medication.

• Audit Procedures: Perform regular audits of medication administration records to ensure compliance with safety protocols.

VII. Signatures

[YOUR NAME], Nurse

June 1, 2050

Dr. Mark Lee, Attending Physician

June 1, 2050

Mr. Eric Berry, Quality Officer/Reviewer

June 1, 2050

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