A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

Choice A Reason:

A nurse discovers that a client's family member has administered a PCA dose: While this is a medication administration concern, it might not always require an incident report, but it should be addressed by the healthcare team to prevent future occurrences.

Choice B Reason:

A nurse observes a client vomiting after receiving an oral pain medication: This could be a medication reaction or a side effect, and it should be documented in the client's medical record, but it may not necessarily require a separate incident report.

Choice C Reason:

A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. Incident reports are typically used to document unexpected events or situations that deviate from the standard of care, and this includes situations where errors occur that could potentially harm the patient. In this case, the IV pump delivering twice the prescribed amount of fluid is a medication error that should be reported to document the occurrence and to ensure that corrective actions are taken to prevent similar incidents in the future.

Choice D Reason:

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: This might be a situation that requires clarification and discussion among the healthcare team, but it may not necessarily require an incident report unless there is concern about patient safety.

Choice A Reason:

Incident report is correct .When a medication error occurs, it should be documented in an incident report. An incident report is a formal record of an event that compromises client safety, such as a medication error. It allows the healthcare facility to investigate the error, take corrective actions, and implement preventive measures to improve patient safety. Incident reports are generally kept separate from the client's medical record to protect the confidentiality of the investigation.

Choice B Reason:

Controlled substance inventory record is incorrect. This record is used to track the administration and wastage of controlled substances and is not the appropriate place to document a medication error.

Choice C Reason:

Provider's progress notes is incorrect. The provider's progress notes are used for documenting the client's medical history, physical examination, diagnosis, treatment plan, and progress. It is not the place to document medication errors.

Choice D Reason:

Nursing care plan is incorrect. The nursing care plan outlines the client's nursing diagnoses, goals, interventions, and outcomes. It is not the appropriate place to document medication errors.