INCIDENT REPORTING SHEET

S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 4/4/2019 MEGHA 15194 290 PRIVATE DR. MEDICATION ERROR WRONG DOCUMENTATION After STAT order of inj. Aciloc 50mg Doctor
ROOM perscribed in next order same inj. Aciloc 50mg 8hourly to patient
but new order charted in same coloum.
RCA:- Do not revised medicine in next coloum. Over counter on
same coloum of medication chart.
CA:- I corrected that mistake and medication on next coloum.
PREVENTION:- Advice to medical offcers to cross check the
medication chart.

2 7/4/2019 JIVESH
15972 305 GENERAL DR. PRATIMA MITTAL MEDICATION ERROR DOCUMENTATION ERROR Inj. Aciloc 25mg given to patient. Time is mentioned
WARD but the staff did not sign on medication chart.
RCA:- Staff was busy.
CA:- Provide training to staff proper signed the medication chart
after each medication with date and time.
PREVENTION:- Education & training given to all nursing staff

3 16/4/19 LALITA 16012 343 PRIVATE DR. ANUPMA CHOPRA MEDICATION ERROR DOCUMENTATION ERROR After STAT order Dr. prescribed inj. Irozorb 200mg on next day
ROOM but same but new order charted in same coloum.
RCA:- Do not revised medicine in next coloum. Over counter on
same coloum of medication chart.
CA:- I corrected that in the next coloum.
PREVENTION:- Advice to medical offcers to cross check the
medication chart.

4 30/4/19 HARLEEN KAUR 14513 401 PRIVATE DR. DEEPALI LUTHRA MEDICATION ERROR ADMINISTRATION ERROR Dr. adviced syp. Bestozyme TDS to patient but evening dose
ROOM were not given by nursing staff.
RCA:- That day is over work load.
PREVENTION:-Training given to all nursing staff.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 19/5/19 GURPREET VIJ 12322 473 DELUXE DR. RAJESHWARI MEDICATION ERROR ADMINISTRATION ERROR Dr. prescribed Syp. Super spas TDS to patient but morning
ROOM dose were not given to the patient.
RCA:- Staff is busy due to staff being on leave.
PREVENTION:- Training is given to the nursing staff.

2 25/5/19 ARAV 16226 509 DELUXE DR. PRATIMA MITTAL MEDICATION ERROR ABBRRVIATION ERROR Dr. prescribed inj. Monocef 500mg BD but mitakenly written
ROOM B/O in place of BD.
RCA:- In frequently writing mistakenly wrote B/O by RMO.
CA:- I correct this error and wrote BD
PREVENTION:- Advice the RMO to cross check all abbriviations
in medication chart .

3 25/5/19 CHARAN KAMAL 4980 513 DELUXE DR. RAJESHWARI MEDICATION ERROR DOCUMENTATION ERROR Doctor prescribed Tab Doxinate Forte 20 mg but in
ROOM medication chart medicine dose is not mentioned.
RCA:- Staff was forget to write the dose in medication chart.
CA:- I wrote the dose & correct the error.
PREVENTION:- Advice the MO to cross check the medication
chart.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-


S.NO DATE PATIENT NAME
1 10/6/2019 Alisha
2 29/6/2019 Kamaljit Kaur
NURSING SUPERINTENDENT SIGN:-
INCIDENT REPORTING SHEET
UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
16286 568 GENERAL DR. RAJESHWARI MEDICATION ERROR ABBRIVIATION ERROR Dr. advise Tinidazole infusion 800mg but in medication
WARD chart mistakenly written 800ml in the place of 800mg.
RCA:- In frequent writing mistakenly write ml
abbriviation in the place of mg
CA:- I corrected the error and wrote mg in thre place of
ml.
PREVENTION:- Advice for cross checking of medication
chart.
16384 628 PRIVATE DR. RAJESHWARI MEDICATION ERROR WRONG TIME I/V Metronidazole 100ml TDS administered to the
ROOM patient but staff has given late evening dose at 5:00pm
but time of medicine is 3:00pm.
RCA:- Staff was busy
PREVENTION:- Training given to the staff to give
medicine all patients on according to the medicine
schedule.
OVER CHECKED BY:-
 INCIDENT REPORTING SHEET
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 12/7/2019 Supriya 15500 687 Deluxe Dr. Rajeshwari Medication Error Wrong Time Error Inj. Ampicillin 2gm I/V Given 2 hours late from due.
room RCA:- Staff is busy due to attend the emergency
patient.
PREVENTION:- Training given to staff to give
medicine at proper time according to schedule.

2 15/7/2019 Sherry
13664 694 Deluxe Dr. Rajeshwari Medication Error Wrong Time Error Inj. Ampicillin 2gm I/V Given 2:30 hours late from
room due.
RCA:-Patient refuse to take antibiotic in early
morning.
PREVENTION:- Training given to staff to councel
the patient about right time of medication and
give medicine at proper time according to schedule
.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 2/8/2019 Paramjit Kaur 16556 781 Deluxe Dr. Deepak Chawla Medication Error Administration Error Inj. Diclofenic 75mg I/M not given evening dose.
Ward RCA:- That day is over work load.
PREVENTION:- Training given to all staff.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

0

INCIDENT REPORTING SHEET

S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 9/9/2019 RAJWINDER 16702 939 Private Dr. Deepak Chawla Medication Error Documentation Error The dose of Tab Trioflam is not wrote on medication
KAUR Room chart.
RCA:- Staff was forget to write the dose in
medication chart .
CA:- I wrote the dose & correct the error.
PREVENTION:- Advice the staff to cross check the
medication chart.

2 18/9/2019 RAVNEET 9233 984 Deluxe Dr. Rajeshwari Medication Error Documentation Error Dr. prescribed I/V Tiniba 400ml OD but mitakenly written
KAUR room mg in place of ml.
RCA:- In frequently writing mistakenly wrote mg by Staff.
CA:- I correct this error and wrote 400ml on medication
chart
PREVENTION:- Advice the MO/Staff to cross check all
abbriviations in medication chart .

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET (OCT 2019)
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
jkj 18/10/2019 Shikha Sharma 16585 1104 Private Dr. Rajeshwari Medication Error Documentation Error Doctor prescribed Suppostry Dulcoflex 10mg but in medication
Room chart drug name and dose is not mentioned .
RCA:- Staff was forget to write the dose and drug name of dulcoflex
in medication chart.
CA:- I wrote the drug name & dose & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

2 19/10/2019 Kajalpreet kaur 13393 1105 Private Dr. Rajeshwari Medication Error Documentation Error Doctor prescribed I/V inj. Monocef 1gm but in
room medication chart medicine form is not mentioned.
RCA:- Staff was forget to write the form of medicine in medication
chart.
CA:- I wrote the form of drug & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

3 20/10/2019 Jashanjot kaur 10005 1107 Deluxe Dr. Rajeshwari Medication Error Documentation Error Doctor prescribed I/V Tiniba 800mg but in
Room medication chart medicine dose is not mentioned.
RCA:- Staff was forget to write the dose in medication chart.
CA:- I wrote the dose & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET (NOV- 2019)
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 6/11/2019 Neeraj Bajaj 16983 1163 Ward Dr. Rajeshwari Medication Error Documentation Error Doctor prescribed Tab Cefixime 200mg but in medication chart
drug form is not mentioned .
RCA:- Staff/MO was forget to write the form of medicine in
medication chart.
CA:- I wrote the drug form & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

2 8/11/2019 Jaspreet Kaur P 1174 Private Dr. Deepak Chawla Medication Error Documentation Error Doctor prescribed I/M inj. Dynapar but in
room medication chart medicine form is not mentioned.
RCA:- Staff was forget to write the form of medicine in medication
chart.
CA:- I wrote the form of drug & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

3 19/11/2019 Baljinder Kaur 16584 1207 Private Dr. Deepak Chawla Medication Error Documentation Error Doctor prescribed Inj. Dynapar 75 mg but in meddication chart
room medicine form is not mentioned.
RCA:- Staff was forget to write the form of medicine in medication
chart.
CA:- I wrote the form the medicine & correct the error.
PREVENTION:- Advice the MO & staff to cross check the medication
chart.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET (DEC - 2019)
S.NO DATE PATIENT NAME UHID IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION
1 10/12/2019 HARWINDER 16114 1288 ROOM DR. SUSHMA CHAWLA Medication Error Documentation Error Doctor prescribed Tab VALIUM(Daizepam) 5mg but in
KAUR NO. 1 medication chart wrong drug name was written by staff
.
RCA:- Staff/MO wrote the wrong drug name i.e tab
Phenergan in medication chart in the place of tab
daizepam.
CA:- I wrote the right drug name on medication chart &
corrected the error.
PREVENTION:- Advice the MO & staff to cross check the
medication chart.

2 23/12/2019 KULDEEP 4567 1324 DELUXE DR. DEEPALI LUTHRA Medication Error Documentation Error Doctor prescribed I/V TINIBA infusion 800mg(400ml)
KAUR WARD but wrote 800ml dose in medication chart.
RCA:- In frequent writing mistakenly ml abbriviation
was written in the place of mg.
CA:- I corrected the error and wrote mg in the place of
ml.
PREVENTION:- Advice for cross checking of medication
chart.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-

 INCIDENT REPORTING SHEET (DEC - 2019)
UHID/
S.NO DATE PATIENT NAME IPD AREA CONSULTANT NAME TYPE OF INCIDENT INCIDENT SUB TYPE DESCRIPTION

1 10/12/2019 HARWINDER 16114 ROOM DR. SUSHMA CHAWLA Medication Error Documentation Error Doctor prescribed Tab VALIUM(Daizepam)
KAUR NO. 1 5mg but in medication chart wrong drug
name was written by staff .
RCA:- Staff/MO wrote the wrong drug name
i.e tab Phenergan in medication chart in the
place of tab daizepam.
CA:- I wrote the right drug name on
medication chart & corrected the error.
PREVENTION:- Advice the MO & staff to cross
check the medication chart.

NURSING SUPERINTENDENT SIGN:- OVER CHECKED BY:-