Topic 12: Reporting and Documenting Irregularities


Understanding and following the protocols for reporting adverse events or medication errors is of utmost importance. This topic will guide you through the essentials of reporting and documenting medication irregularities .

Don’t Panic

The irregularity may indicate the wrong medication, wrong client, wrong route, wrong time, wrong dose. You will need to determine what the client was supposed to receive, when they were to receive or what they should have received.

Check the client’s file, are they allergic to the medication that was given?

  • If yes: Continue to observe the client and the allergic reaction, if you see any tongue swelling, or the client has difficulty breathing, call 911.
  • If no: The appropriate supervisor will ensure that the employee has taken the necessary steps to ensure client safety and may take other steps as required.

It is important to do the following:

  • Ensure client safety and well-being
  • Immediately notify the appropriate supervisor
  • Document the irregularity and complete an incident report
  • Provide a copy of the completed incident report the appropriate manager or designate.

Missed Doses

If you notice a medication was not given do the following:

  • Call the pharmacist
  • Notify your supervisor
  • Complete an incident report

Refusing Medication

Clients have the right to refuse their medication.

  • A client may be a Community Treatment Order (CTO). This means they must take their medications.
  • Report the situation to your supervisor immediately.
  • The supervisor will follow-up appropriately on the situation.

The Importance of Accurate Reporting

  1. Accountability: Incident reporting provides a transparent record of what happened.
  2. Learning: By documenting irregularities, organizations can learn and improve their processes.
  3. Legal Requirements: In many cases, proper documentation and reporting of irregularities are not just best practices but legal requirements.

What to Include in an Incident Report

  • Detailed Description: Provide a clear and concise description of the incident. Avoid vague language and stick to the facts.
  • Affected Individuals: Note the details of individuals involved, including their names and their role (patient, staff, visitor, etc.).
  • Time and Date: Record the exact time and date the incident occurred. This helps in tracking and investigating the incident.
  • Actions Taken: Document the immediate actions taken following the incident. This includes any first aid provided, notifying supervisors, or additional medical attention sought.

Q&A on Reporting and Documenting Incidents

  • Q: What information should be included in an incident report?
    A: An incident report should include the specifics of the incident, identities of the individuals involved, the exact time and date of occurrence, and the actions taken post-incident.

Scenario-Based Example: Handling a Medication Error

Imagine you’re a support worker and you’ve inadvertently given a client the wrong medication. Here’s how you should proceed:

  1. Immediate Action: First, ensure the safety and well-being of the client. Take any necessary medical steps or seek help if required.
  2. Notify Supervisors: Inform your supervisor or the in-charge healthcare professional immediately about the error.
  3. Fill Out an Incident Report: Start by detailing the error — what medication was given, what should have been given, and how the error was identified. Include your name, the client’s name, and the time and date of the incident.
  4. Describe Actions Taken: Document the immediate steps you took upon realizing the error, such as any medical interventions or notifications.
  5. Review and Learn: After the incident, review what led to the error and how such mistakes can be avoided in the future. This may involve re-training or changes in medication handling procedures.


As a support worker, understanding the importance of reporting and documenting incidents is crucial. By adhering to documentation standards and properly filling out incident reports, you contribute to the safety and well-being of your clients, while also fostering a culture of transparency and continuous improvement in your workplace.