CC-UC-00902 - Medication Administration - Incident

Actors

• Client/client caregiver
• Registered nurse (RN)

Pre-conditions

• Client is having an adverse reaction to a medication that was administered.
• The correct dose, quantity were administered.
• The medication administered was not expired.

Step	Description	Data elements collected	Result
1	Client experiences a reaction to medication.	Medication Incident Description	Client experiences an adverse reaction to a medication administration. Details are recorded in the client's medical record.
2	RN assesses reaction and provides appropriate interventions to alleviate reaction symptoms and minimize client harm.	Medication Incident Description	The client's reaction is managed, appropriate interventions are provided to minimize harm, and the client's medical record is updated.
3	RN completes a detailed incident report including details related to events that occurred, process followed to notify client/client caregiver, disclosure of the event to clinic manager/ordering provider and client harm scale assessment.	Medication Incident Description	A detailed incident report is completed and recorded in the client medical record.
4	The RN provides the client with instructions for managing symptoms and guidance on when to seek additional care, as needed.	Not applicable	The client receives instructions for managing symptoms and seeking additional care as needed, and the client's medical record is updated.
5	The client leaves the clinic once stable.	Not applicable	Not applicable
6	This use case ends.	Not applicable	Not applicable

Post-conditions

• The client's reaction is managed; appropriate interventions are provided to minimize harm.
• A detailed incident report is completed.
• The client receives instructions for managing symptoms and seeking additional care as needed.
• The client's medical record is updated.

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If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca