MEDICATION ERROR REPORT FORM
NO BLAME NO PUNISHMENT
(Please fill all application information)
1. Date when events occurred (Day/Month/Year):
2. Time of events:
3. Report date (Day/Month/Year):
4. Diagnosis
5. Brand and Generic name: ……………………………………………………………………………………………………………… Drug strength: ………………………………………………………………….……
Dosage form: ……………………………………………………………………………………………… Route of administration: ……………………………………………………………………………………….………
6. Where did the initial error occurred? ………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. Type of error (may select more than one):
Omission error Wrong dosage form
Improper dose (over, under or extra dose) Wrong time of administration
Wrong patient Deteriorated/Expired technique
Wrong drug Deteriorated/Expired medication
Wrong strength/concentration Monitoring errors – Clinical intervention or information
Wrong route Monitoring errors – Drug-Drug interaction
Wrong frequency Monitoring errors – Drug-Food interaction
Wrong rate of infusion Monitoring errors – Drug-Disease interaction
Wrong dilution Other, specify
8. Stage(s) involved: (may select more than one):
Physician ordering Dispensing and delivery Monitoring (drug level/allergy/interaction/clinical)
Transcription and entering process Administration process
Other …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. Description of error (circumstances relating to the event. All information from the beginning to the resolution of event) :
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. How event discovered?
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
11. Used by patient: Yes No
12. Outcome (select only one)
Circumstances/events with capacity to cause error
Error occurred but did not reach the patient
Error occurred but did not harm
Error reached the patient & required monitoring
Error reached the patient & result in temporary harm & required intervention
Error reached the patient & result in permanent harm
Error reached the patient & required intervention necessary to sustain life
Error reached the patient & contributed to patient`s death
N.B (Index 4) immediately notify the sentinel event committee
13. Error made by (who initiated the error):
MD/Physician Dentist Other …………………………………………….…
Pharmacist Patient / Caregiver
Nurse (Radiology, OR, RT, Lab, Pharmacy)
Page 1 of 2
14. Error reported by:
MD/Physician Dentist Other …………………………………………….…
Pharmacist Patient / Caregiver
Nurse (Radiology, OR, RT, Lab, Pharmacy)
15. Was the error repeated? Yes No
(If Yes, explain) ……………………………………….………………………………………….………………………………………….………………………………………….…………………………………………
16. Cause(s) of error / contribution factor(s) (may select more than one):
Clinical information missing (lab results or vital signs)
Drug information missing
Miscommunication of drug order (illegible, ambiguous, incomplete)
Look-Alike and Sound-Alike medication problem
Drug name, label, filling and package problem
Drug storage or delivery problem
Environmental, staffing deficiency and workload problem
Lack of staff education and training problem
Patient education problem
Independent double check system
Other, specify: ………….………………………………………….………………………………………….………………………………………….……………………………………………….………………
17. Action taken for resolution (For Pharmacist or Nurses):
Call physician for verification for emergency order
Clinical intervention
Education & Training of medical staff
Send pharmacists note to physician for clarification
Change to correct dose
Perform root cause analysis
Discontinue one drug (improper combination)
Return drugs to pharmacy
Drug not dispensed to patient
Memo sent to department
Other, specify………….………………………………………….………………………………………….………………………………………….………………………………………….………………………
18. Intervention action taken for resolution (For physician) (IF NEEDED)
Testing Care escalated Others ………………………………………………………………………….………
Additional observation Additional LOS ………………………………………………………………………….………………….……
Give antidote Change to correct drug, dose, frequency, duration
19. Recommendation (Suggestion on how to prevent recurrence of this error)
…….………………………………………….………………………………………….………………………………………….…………………………………….………………………………………….…………………………………
…….………………………………………….………………………………………….………………………………………….…………………………………….………………………………………….…………………………………
…….………………………………………….………………………………………….………………………………………….…………………………………….………………………………………….…………………………………
Please send complete form to Medication safety unit
``
Page 2 of 2
