Medication Error Reporting

Voluntary medication error and near-miss reporting for safety learning

Reporting medication errors is MANDATORY and confidential. Near-misses are equally important. No punitive action for voluntary good-faith reports.

Errors This Month

3

Severe / Death

1

Near Misses

1

Actions Completed

3/3

ME-2026-041 — Rajan Mehta (ICU-1)

22 Jun 2026 · Drug: Heparin · Reported by: Dr. R. Iyer

Category: Wrong dose

Intended: 5,000 U SC BD → Given: 50,000 U SC — decimal error

Action: Protamine sulphate reversal given. Patient recovered. RCA initiated. Heparin now issued only in unit-dose packaging.

Severe harm

ME-2026-040 — Priya Sharma (GW1-5)

20 Jun 2026 · Drug: Metformin vs Metoprolol · Reported by: Staff Nurse K. Nair

Category: Wrong drug

Intended: Metoprolol 50 mg OD → Given: Metformin 500 mg — similar pack, dispensed in error

Action: Near miss — caught by nurse before administration. Root cause: look-alike storage. Drugs separated in dispensing area.

No harm

ME-2026-039 — Gopal Mehta (GW2-3)

18 Jun 2026 · Drug: Furosemide · Reported by: Staff Nurse A. Kumar

Category: Omission

Intended: Furosemide 40 mg OD → Given: Omitted — missed from MAR

Action: Dose administered 4 hours late. No significant clinical impact. MAR process reviewed with ward team.

Minor harm