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SYNERGY 9 ===
<) Synergy Multispeciality Hospital
JS suensrnciariry ttosrriat Medication Error Reporting Form
Please tick the appropriate box. All fields must be filled except details of reporter which is optional.
9. Possible causes & contributing factors:
1. Date of event: 2. Location of event:
Time of event: Ward OPD Pharmacy Others
3. Type of error: 4, Patient details:
Prescribing Dispensing Age: Gender:
‘Administration Others (specify) Diagnosis
5. Description of the event: (how the event occur and how was it detected?)
6. Details of medicines involved in the event: 7. Did the error reach the patient?
Yes No
no] P2588 | Generic Name _|strength| Frequency]
8, Outcome of the event:
No error Error, harm
COA. Eventshave — [] E, Temporary harm
potential to requiring treatment
cause error
Error, No harm
CIF. Temporary harm
requiring
He. Error did not hospitalization
Lack of knowledge / Unavailable patient teach patient
experience: infomation G, Permanent harm
nears Ce term =F
legible prescription eak hour OOH. Near death event
LAD. Noharm but
Look alike / sound alike Miscommunication feds Error, death
medication monitor eat
LFaiture to adhere to work " CE te
[wrong labeling instruction procedure 10. Details of reporter: (optiona
Use of abbreviations [_] Others __ Name:
Designation:
Mobile No:
11. Intervention done:
Administered anticote Changed to correct drug / dose /frequency [_] No action needed
Education training provided ‘Communication process improved Others (specity)
Informed staff who made error Policy / procedure changed / instituted
