ADVERSE EVENT (MEDICATIONERROR) REPORTING FORM
Patient Name MR No
Location Primary Physician
Patient diagnosis /Clinical details
Description of Error:
Patient condition after Error:
_____________________________________________________________________________________________
Person/s involved:
_____________________________________________________________________________________________
Category OF Medication Error: (Circle condition applicable)
1) Category A: circumstances or events that have the capacity to cause error.
2) Category B: An error occurred but did not reach the patient for example. An “error of omission “does not
reach the patient.
3) Category C: An error that reached the patient but did not caused any harm.
4) Category D: An error occurred that reached the patient and required monitoring to confirm that it resulted no
harm to the patient.
5) Category E: An error that may have contributed to or resulted in temporary harm to the patient and required
interventions.
6) Category F: An error occurred that may have contributed to or resulted in temporary harm to the patient and
required initial or prolonged hospitalization.
7) Category G: An error occurred that may have contributed to or resulted in permanent patient harm.
8) Category H: An error that required an intervention necessary to sustain life.
9) Category I: An error that may have contributed or resulted in the patient’s death.
Classification Of Medication error: (circle condition applicable)
Prescribing Error related to Dispensing Error related to Administrating Errors Related to
physician pharmacist Nurse
Over dose Wrong Dose Wrong drug
Wrong drug Name/wrong entry Wrong duration Wrong Dosage
Wrong doses Wrong Drug Wrong patient
Wrong uses of decimal points Wrong frequency /instruction, Wrong schedule
precautions.
Wrong route of administration Wrong route of administration Wrong time
No strength Wrong dosage form Wrong Route
No stop date Wrong patient identification Wrong additives
Not follow Drug-drug interaction Wrong label Wrong Fluid
Missing Important Auxiliary label Wrong Storage
for instructions.
Using unapproved abbreviation for Wrong LASA (look alike, Sound IV Set Leaking
drug name. alike) medications.
Patient allergy not written Wrong additives Problem with Fluid
Delay Time for Dispensing Delay in receiving Medicine
Poor hand writing Extra additives Extra/missed dose
Generic name not used Fluid problem with fluid IM complication
formulation
Expired Drug Miscellaneous
Description of any other Event:________________________________________________________________
___________________________________________________________________________________________
PROCEDURE SEQUENCE Responsible Check
1 The Physician who prescribed the medication must be notified of error. Pharmacist/Nurse
2 The pharmacist who dispensed the medication must be notified of the error. Physician/Nurse
3 The Nurse who administers the medication must be notified of the error. Pharmacist/physician
4 Any medication prescribing error must be reported immediately to the Pharmacist/Nurse
attending physician and nursing TL.
5 Any medication dispensing/administrating error must be reported to the Physician/Nurse
attending physician and nursing TL.
6 Documentation should be done by the person who discovers the error. Physician/pharmacist
Nurse
7 An incident report(in case it reach the patient)to be sent within 24 hours to HOD Pharmacy
the quality improvement office via nursing-pharmacy manager/Head of
Nursing TL
Department
Report is not to be placed in patient’s charts
8 Patient who received the medicine must be contacted(in case of outpatient to Pharmacy
correct the dispensing error staff/physician/Nurse
9 The Person discovering the error must make the incident report Physician/Pharmacist/Nurse
10 The patient condition and vital sign must be closely monitored until stable. Physician/ Nurse
11 Quarterly QI report must be completed and submitted to the quality QI Officer
improvement office.
/QI pharmacist
12 Report is not to be placed in patient’s Charts. QI coordinator
