A nurse discovers they administered a medication to the wrong patient. After taking immediate steps to assess the patient and notify the provider, what must the nurse do?

MEDICATION ERROR REPORTING is mandatory for patient safety, quality improvement, and legal protection. It is also an ethical obligation.

Immediate actions after a med error: (1) ASSESS the patient for harm — vital signs, symptoms, allergic reactions; (2) NOTIFY the prescriber immediately — they need to know to order monitoring or treatment; (3) NOTIFY the charge nurse; (4) STAY WITH the patient as needed for safety monitoring.

Documentation requirements: (1) MEDICAL RECORD: Document the error factually and objectively: what was given, what should have been given, what assessment was performed, what the provider was notified of, and what orders were received; state facts, not opinions or excuses; do NOT write 'incident report completed' in the chart — this creates a paper trail that can make the incident report discoverable; (2) INCIDENT/OCCURRENCE REPORT (separate from the chart): Document for quality improvement purposes; this report typically has some legal protection from discovery; it is the vehicle for system improvement; (3) NEVER ALTER THE CHART or omit information — falsifying a medical record is fraud and a serious criminal offense.

Why reporting is essential: 80-90% of medication errors reach the patient; of those, most do not cause harm (near-misses); systematic reporting allows identification of patterns (wrong patient errors often cluster around look-alike/sound-alike names); process improvements (two-identifier verification, CPOE, barcode scanning) came from error reporting.

Self-disclosure to patient: Facility policy governs this; generally, the nurse and physician together disclose significant errors to the patient as part of the duty of candor.