How to Document a Medication Waste Error with Wrong Dose Recorded
You must immediately file a corrective incident report documenting that the actual waste occurred correctly with a witness present, but the documentation recorded an incorrect dose amount. This is a documentation error, not a waste procedure error, and requires transparent correction through your facility's non-punitive error reporting system 1.
Immediate Documentation Steps
Create an incident report that clearly states:
- The medication was physically wasted correctly with appropriate witness verification 2
- The documentation error: what dose was recorded versus what dose was actually wasted 3
- The witness who observed the correct waste procedure 2
- That no medication diversion occurred—this was purely a transcription/documentation error 3
Why This Must Be Reported
Good communication and record keeping are essential contributions to error reduction, and documentation errors represent system vulnerabilities that must be addressed even when no patient harm occurred 2. The evidence shows that:
- Near misses and errors that did not reach patients should be reported to prevent future harm and improve system safety 1
- Detection of errors is necessary to identify common problems in your setting and prevent recurrence 2, 1
- Approximately 20% of medication errors are near misses caught before reaching patients, and all should be reported regardless of outcome 1
The Non-Punitive Approach
Your facility should have a blame-free, non-punitive reporting environment where documentation errors can be disclosed without fear of punishment 4, 1. The evidence is clear that:
- Reporting should be encouraged by creating a non-punitive environment, as errors are predictable outcomes of flawed processes, not individual incompetence 4, 5
- The "blame and shame" culture perpetuates unsafe practices and fails to address systematic vulnerabilities 5
- Non-punitive incident reporting systems allow near-misses and errors to be analyzed to improve system design 5
What NOT to Do
Do not attempt to "fix" the documentation by altering records without filing an incident report—this creates a falsified record and compounds the error 2. Documentation errors must be corrected through proper channels with full transparency 2.
Do not assume this is too minor to report—documentation errors in controlled substance waste represent the exact type of system vulnerability that can lead to more serious errors if not addressed 2, 1.
Follow Your Facility's Specific Protocol
Contact your pharmacy department or nursing supervisor immediately, as most facilities have specific policies for medication error documentation that may include 6:
- Placing documentation in incident reporting systems (not necessarily personnel files for minor errors) 6
- Differentiating between errors caught before versus after leaving the pharmacy 6
- Specific procedures for controlled substance documentation corrections 6
System-Level Prevention
This incident should prompt review of your facility's waste documentation system to prevent recurrence 2, 1. Consider whether: