INC-1041

criticalroot cause

Medication error — missed dose

Naomi Clarke · Cedar Court Home · Cedar Court Home

Notification deadline2h 0m overdue

3 requirements outstanding — closure is blocked until each is evidenced.

Incident facts

Occurred

Sep 13, 02:12

Reported

Sep 13, 03:12

Reported by

Maya Whitfield

Owner

Nurse / Clinical

Witnesses

Maya Whitfield

Linked service event

Description

Scheduled evening anticonvulsant dose was not documented as administered. Staff medication credential was expired at time of shift.

Immediate action taken

Nurse consulted, prescriber line contacted, individual monitored per protocol.

Billing impact: Linked service on billing hold — qualification failure

Action	Owner	Due	Status
Block scheduling of medication-required shifts for expired credentials	Jules Whitmore	Sep 13, 2026	overdue
Complete medication administration recertification for Maya Whitfield	Nadia Farouk	Sep 20, 2026	open

Immutable record of every action on this incident

Timestamp	User	Action	Old → new	Reason
Sep 13, 13:12	Terrence PooleQA Manager	Corrective action assigned	— → open	Root cause: credential enforcement gap

Closure is blocked until every item is evidenced

Recipients and windows derived from the matching rule

Rule

Medication error review

Trigger

Incident type contains 'Medication'

Window

8 hours from report time

Escalation

Nurse review required before closure

Notify

Nurse / Clinical, QA / Compliance