NCLIP

Medication Error Reporting and Escalation

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Medication Error Reporting and Escalation

Key Points

  • Prompt reporting of medication errors and adverse reactions is a core nursing safety duty.
  • Escalation includes immediate patient assessment, provider notification, and complete objective documentation.
  • Standardized terminology and approved abbreviations reduce secondary documentation errors.

Equipment

  • MAR and full medical record access
  • Facility medication-event reporting tool/process
  • Approved abbreviation reference (including do-not-use list)
  • Immediate communication channel for provider/team notification

Procedure Steps

  1. Recognize potential medication error, near miss, or adverse reaction during/after administration.
  2. Assess patient immediately for stability, symptom severity, and required urgent intervention.
  3. Notify provider and appropriate clinical leadership per policy without delay.
  4. Carry out any immediate safety orders and continue close monitoring.
  5. Document objective event details in MAR/progress note, including time, medication, dose, route, and observed response.
  6. Include provider notification details and additional orders received.
  7. Complete required incident-reporting workflow according to organizational policy.
  8. Use approved abbreviations only and avoid error-prone shorthand or symbols.
  9. Reassess patient response after interventions and document outcome trends.
  10. Communicate relevant findings during handoff to preserve continuity and safety.

Common Errors

  • Delayed reporting after adverse response → slower treatment and higher harm risk.
  • Incomplete event details → unsafe handoff and weak root-cause follow-up.
  • Use of nonapproved abbreviations → misinterpretation and repeat errors.
  • Failure to reassess after escalation → missed ongoing deterioration.

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