A nurse is documenting an incident report for a medication error that occurred on her unit.

Which of the following actions should the nurse take?

(Select all that apply.).

The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.

Choice B is wrong because the nurse should not state opinions about who was responsible for the error.

This could be seen as biased, unprofessional or accusatory.

The nurse should focus on the facts and the causes of the error, not on blaming individuals.

Choice C is wrong because the nurse should not file the report in the client’s medical record.

This could violate the client’s privacy and confidentiality.

The report should be filed in a separate system that is accessible only to authorized personnel.

Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.

This could be premature, unrealistic or inappropriate.

The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.

Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.

Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.

Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.

Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.

SOAP format helps to organize the information collected from the patient in a clear and consistent manner.

It consists of four components:.

• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.

• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.

• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.

• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.