Medication Log

Incorrect Dosage

Date, Time, and Place of Incident

This report gives the details of an incident that occurred on April 13, 2020, and 2:00 PM at
Phoenix Place.

Nature of Incident

Incorrect medication dose was given to a resident

Name of person involved

Bill Wright – individual who was given the incorrect dosage

Allie Bogris– staff member who administered the incorrect dosage to Bill

Louise Berkley – staff member

Events leading to the incident

In the afternoon, I called Bill into the dining room to take his medication. After I got the
medication from the cupboard, I administered the medication to Bill at 2:00 PM.

Events during the incident

After I gave Bill his 54mg of Concerta at 2:00 PM, he headed upstairs to his room. Then, as I
was putting the medication bottle back in the cupboard, I noticed that the name on the
bottle wasn’t Bill’s name. After double-checking that it wasn’t for Bill, I went upstairs to
check on how he was feeling. After I checked that he was okay, I went downstairs and called
the pharmacy immediately. I told the pharmacist that I had accidentally given a resident
someone else’s Concerta prescription, and that Bill was supposed to have 45mg instead of
54mg. I then wrote down what the pharmacist suggested I do, which was to keep my eye on
how he was feeling and if he has any adverse reactions to the medication. After the
pharmacist and I finished our call, I notified the staff on shift after me, Louise, that I had
given Bill the incorrect dosage for his Concerta. She said that she will keep an eye on him
while she is on shift, and then told me to make sure that I write a medication incident
report about what happened today. I also called to let my supervisor know what had
happened, and that I had taken all the necessary precautions following the incident.

Allie Bogris