Question

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

A. Nurse's personal opinions about the error
B. Actions taken to correct the error
C. Names of other staff present during the error
D. Apology to the client for the error

Answer 1

The nurse should document the actions taken to correct the error in the client's medical record.

Step-by-step explanation:

The nurse should document the actions taken to correct the error in the client's medical record. This includes any immediate steps taken to address the incorrect dose of medication, such as notifying a superior, consulting with another healthcare professional, or adjusting the client's treatment plan if necessary. Documentation of the actions ensures continuity of care and promotes transparency in the healthcare team.

It is not necessary for the nurse to document personal opinions about the error in the client's medical record, as these opinions can subjective and may not contribute to the client's care. Similarly, names of other staff present during the error are not typically necessary to be documented in the medical record, as the focus should be on the client's care and any actions taken to address the error. While the nurse should apologize to the client for the error, this can be done directly with the client and does not need to be documented in the medical record.