Palestinian National Authority

Ministry of Health - Nursing Dept.

Palestine College of Nursing

Incidence Report Form for Management's Students

Date : 30/3/2013 Time : 13 pm Outpatient Visitor
Please use 24 hour clock

Inpatient

Equipment / property Staff Patient Visitor . . Exact location : Room #2 Male . . . . Non-medication incident

Name of witness / First person to attend: Ward / Department : neurosurgery unit Patient admission diagnosis : C.S.F leakage

Medication incident . . Description of what happened: Brief description of the incident including the immediate actions and outcome. Doctor prescribed for pt. 500mg Rocephin , M.R Nurse give the pt. 500 mg vancomycin on , then the nurse administer The drug iv push without biuret , after 10 minutes the pt. family shut that there is something wrong, the M.R Nurse go To pt. then he became to me and told me that there is abnormal features on pt. itching and flushing of the face, neck, & torso , I ask him what did you give him and he told me that he give him vancomycin , then I now that the condition its red man Syndrome. Immediate actions and outcome : The first step I informed the head nurse and the doctor immediately and prescribed for him the condition, they coming and say that the condition was red man syndrome The doctor prescribed for him anti histamine and mild Topical steroid, wet raps for the pts. skin , and stop all un needed medications, after 15 minute the pt. condition began to stabilize
Contributing Factors: Consider system, staff, and patient and visitor issues - did any of these contribute to the incident. What occurred before
the incident?

The main cause that the nurse doesn't has enough knowledge about drugs, also the overload on the nurse caused him To loss his consideration, also the nurse is newly graduated nurse
Prevention :
Ideas of how this could have been prevented

The newly graduated nurse need for lectures on the medication and the common precautions also the nurse should confirm the medication before they give it , and the nurse in some times need for break times to reduced stress and tension Medical staff notified?
Medical Report: Yes . . No N/A
Document patients assessment and list investigations and treatments.

Male pt 60 years old , known case of HTN, admitted to hospital after C.S.F Leakage , loss of balance , headache and general Fatigue Hgb 12.5 g/dl. Medications: Vancomycine, dexamethasone, Ranitidine.

Doctors Name: Nabil Ahalaq Reported By: Monther Alkharaz Position : BSN Nurse Contact No : 0592249594

Designation:

Date/Time: Saturday 30/3/2013 at 2 pm

Other Persons involved: Ahmed Abu Hilal Position: BSN Nurse Contact No : 059226825

205024 : 7049 : . 2050230:

Palestine College of NursingKhan Younis El-Fukhari: P.O.Box:7049E-mail
pcngaza@gmail.com