Palestinian National Authority ‫السلطـــة الوطنيـــة الفلســطينيـة‬

Ministry of Health - Nursing Dept. ‫وزارة الصحة – وحدة التمريض‬

Palestine College of Nursing ‫كليــــة فلســــطين للتـمـريـــــض‬

Incidence Report Form for Management's Students

Date : 09/2/2020 Time : 11:30 AM
 Inpatient Outpatient Visitor Equipment / property
Name of witness / First person to attend:  Staff Patient Visitor
Ward / Department : ccu Exact location :medication preparation room

Patient admission diagnosis : inf mi.

 Medication incident Non-medication incident

Description of what happened:

During the medication preparation for the patient ali baraka. The student who was preparing the
Cefuroxime medication for pt. had diluted it by Ventolin instead of distal water. And then while giving it
to the pt. it cause irregular heart rhythms and tachycardia.
Immediate actions and outcome :
The first step, I stopped the medication. And informed the head nurse and the doctor immediately and
prescribed for him the condition, then we take the vital signs for the pt. and administered oxygen
therapy for pt. and put him in semi fowler position. after 15 minute the pt. condition began to stabilize
Contributing Factors:
The main cause that the student doesn't check the medication three times during preparation and the
negligence of the student. And because of the over load of work led student loss his concentration, also
the student nurse is new and had no experience.
Prevention :
The student nurse need for more attention and commitment of the basic steps and standard while
preparing the medication And to confirm the medication before giving it

Medical staff notified?  Yes No N/A

Medical Report:
male pt. 34 years old, diagnosed as Gunshot Rt femur was admitted to the Medical surgical ward for
remove the shot from Rt femur. Currently pt. is stable and still under the medical and nursing
observation.
Doctor’s Name: Designation: Date/Time:

Reported By: Other Persons involved:

Position : BSN Nurse Position: Clinical Instructor
Contact No : Contact No :

2050230: ‫ – فاكس‬205024 : ‫– تليفون‬7049 : ‫ب‬.‫كلية فلسطين للتمريض – خانيونس الفخاري ص‬

Palestine College of Nursing–Khan Younis El-Fukhari: P.O.Box:7049–E-mail pcngaza@gmail.com
Palestinian National Authority ‫السلطـــة الوطنيـــة الفلســطينيـة‬
Ministry of Health - Nursing Dept. ‫وزارة الصحة – وحدة التمريض‬
Palestine College of Nursing ‫كليــــة فلســــطين للتـمـريـــــض‬

2050230: ‫ – فاكس‬205024 : ‫– تليفون‬7049 : ‫ب‬.‫كلية فلسطين للتمريض – خانيونس الفخاري ص‬

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