How should a medication error be documented in the patient record?

• A. Erase and rewrite
• B. Delete the entry
• C. Ignore
• D. Do not erase; draw a single line through the error, initial/date, write the correction, and document per policy; inform relevant staff

Answer: (D)

When a medication error occurs, the record must remain an accurate, traceable account of what happened. Do not erase or delete the erroneous entry. Instead, draw a single line through the error so the original text is still legible, initial and date to show who made the correction, and then write the corrected information in the same entry. Follow the facility’s policy for how to document the correction and any required details. Also inform the relevant staff and document all actions taken, including the time of the event, the medication involved, the type of error, steps taken to mitigate harm, the patient’s status, and who was notified. This preserves an intact audit trail, supports patient safety and accountability, and aligns with legal and regulatory expectations.