Medication Error Incident Report

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I. Incident Description

On May 30, 2050, at approximately 10:00 AM, a medication dispensing error occurred in the Endocrinology Unit at [YOUR COMPANY NAME]. The patient, Mr. Leon Hanson, received a double dose of insulin due to a miscommunication between the nursing staff and the pharmacy. The error was discovered when Mr. Hanson experienced symptoms of hypoglycemia shortly after the administration.

II. Date and Time of Incident

• Date: May 30, 2050

• Time: 10:00 AM

III. Medication Details

Medication Name	Dosage Prescribed	Dosage Administered	Route
Insulin Glargine	10 units	20 units	Subcutaneous

IV. Patient Information

• Name: Mr. Leon Hanson

• Age: 45

• Gender: Male

• Diagnosis: Type 2 Diabetes Mellitus

V. Individuals Involved

Name	Role	Responsibility
Nurse [YOUR NAME]	Administering Nurse	Administered the medication
Pharmacist John Brown	Dispensing Pharmacist	Dispensed the medication
Dr. Emily White	Attending Physician	Ordered the medication

VI. Type of Error

• Classification: Medication Dispensing Error

• Description: The patient received a double dose of insulin due to a miscommunication during the medication handoff process.

VII. Consequences

Mr. Hanson exhibited symptoms of hypoglycemia, including sweating, dizziness, and confusion. Immediate action was taken to stabilize his blood glucose levels. He was closely monitored and fully recovered without long-term effects.

VIII. Root Cause Analysis

The root cause of the error was identified as a breakdown in communication during the medication handoff process. The nurse misinterpreted the pharmacist’s instructions, leading to administering a double dose of insulin.

IX. Corrective Actions

1. Staff Education and Training: Conducted additional training sessions for nursing and pharmacy staff to reinforce proper communication protocols during medication handoff.

2. Policy Review and Update: Updated the medication administration policy to include a double-check system where another nurse or pharmacist verifies the dosage before administration.

3. Implementation of Technology Solutions: Introduced electronic medication administration records (eMAR) to reduce the likelihood of human error.

X. Signatures

Prepared by:

Nurse [YOUR NAME]
Date: May 31, 2050

Reviewed by:

Dr. Emily White
Date: May 31, 2050

Approved by:

[YOUR COMPANY NAME] Risk Manager
Date: June 1, 2050

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Organization: [YOUR COMPANY NAME]
Address: [YOUR COMPANY ADDRESS]
Contact Number: [YOUR COMPANY NUMBER]
Website: [YOUR COMPANY WEBSITE]
Email: [YOUR COMPANY EMAIL]

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