A nurse discovers a medication error — administered the wrong dose of a non-critical medication to a stable patient. The patient appears unaffected. What must the nurse do?

Medication error reporting:

Moral and legal obligation: All medication errors must be reported, regardless of apparent harm — this is a patient safety, legal, and regulatory requirement.

Immediate response: Assess patient for signs of adverse effects (vital signs, symptoms); report to RN and physician immediately with specific information (what was given, what was ordered, when, patient status).

Documentation: Document WHAT WAS ACTUALLY ADMINISTERED in the medical record — falsifying to show the correct dose is fraud; the incident report is separate from the medical record.

Incident report: NOT part of the medical record in most jurisdictions; used for quality improvement; typically not discoverable in litigation; DO NOT reference the incident report in the medical record.

Consequences of not reporting: The physician may unknowingly give subsequent orders based on the assumed correct medication; harm could result later; the nurse faces discipline and potential criminal charges for concealment.

Just culture: Modern healthcare uses a 'just culture' model — transparent reporting without automatic punishment for honest errors; learning-focused rather than blame-focused.