CHRONOLOGY

Patient Name : Lee Jun Jie

I/C : 901125-01-5723

MRN : 28705

Date of Admission : 23/7/2021

Bed no. : 501

Consultant : Dr Rishdawati, Dr Mohd Fadri

Diagnosis : Bilateral hemispheric intracranial bleed with mass effect, bilateral

bronchopneumonia with pulmonary sepsis.

DATE CHRONOLOGY

5/8/2021 @ I went to level 6 to fetch patient, Fatimah binti Kasni (MRN: 29518). Patient is to
1730 transfer to level 5 at room 528. I completed all the assessment for the patient.

5/8/2021 @ I start to give medication for level 5 (medication round).

1800 At the same time, got call from pharmacy to take medication (new patients and for new
ordered)

5/8/2021 @ Went down to pharmacy to take all medications.

1805

5/8/2021 @ Started to serve medication for pm shift.

1815

5/8/2021 @ I am giving and explained about the medication to his girlfriend.

1830 Patient rest in bed, was eating accompanied by his girlfriend. No complaint noted.

Vitals sign @ 1800H:

BP: 124/71 mmHg

PULSE: 56 bpm
TEMP: 36.3 c
SPO2: 100%
PAIN SCORE: 2/10

When I serve medication for this medication, I only saw the ordered of tab nootrophil
1200mg. The medication is still in the slot. I didn’t know that the doctor already change
the medication to 800mg dose. The medication of 1200mg was not discontinued in the
system. I also didn’t aware there is a new order of tablet nootrophil 800mg.

5/8/2021 @ I finished served medication during my shift.

2000

6/8/2021 @ I received WhatsApp message from RN Tunku Nur Ain, that I was given the wrong
0700 dose of Tab Nootropil. Instead of 800mg, I served 1200mg.

UM Anita Ismail already informed by the pharmacist about this incident.

Prepared by,

(RN Nor Samilah Mohd Ismail)