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Free Medication Error Template

The Medication Error Form is a crucial document used to report any incidents or discrepancies related to medication administration. This form helps ensure patient safety by documenting errors, whether they involve incorrect dosages, wrong medications, or other issues that could impact health. If you encounter a medication error, please fill out the form by clicking the button below.

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Table of Contents

The Medication Error form serves as a crucial tool in ensuring patient safety and enhancing the quality of care within healthcare settings. This form is designed for reporting all types of medication incidents and discrepancies, allowing pharmacists to document errors that may impact patient health. When a pharmacist identifies a medication error, they are responsible for initiating the report, which includes detailed patient information such as name, address, phone number, and relevant prescription details. The form captures essential data regarding the nature of the incident, whether it involves incorrect dosing, wrong medication, or other discrepancies. Additionally, it requires the pharmacist to notify both the physician and pharmacy manager about any incidents that could potentially harm a patient. The form emphasizes the importance of documenting contributing factors, such as improper patient identification or miscommunication, which may have led to the error. Following the incident, the pharmacist must assess the severity of the situation and outline the necessary follow-up actions to prevent future occurrences. By systematically addressing medication errors, this form not only aids in immediate patient care but also fosters a culture of safety and accountability within the pharmacy practice.

Document Specifics

Fact Name	Description
Purpose of the Form	This form is used for reporting all medication incidents and discrepancies. Pharmacists have the discretion to report discrepancies.
Initiation of Report	The pharmacist who discovers the error is responsible for initiating the report.
Notification Requirement	It is crucial to notify both the physician and the pharmacy manager of any medication incidents that may affect a patient's health or safety.
State-Specific Laws	The governing laws for medication errors may vary by state. It is important to refer to local regulations for compliance.

Similar forms

Incident Report Form: This document is used to report any event that could harm a patient or disrupt normal operations. Like the Medication Error form, it requires details about the incident, including who was involved and what happened. Both forms aim to improve patient safety by documenting errors and near misses.
Patient Safety Report: This report focuses on potential risks and safety issues within a healthcare setting. Similar to the Medication Error form, it encourages reporting of incidents to identify trends and implement preventive measures. Both documents emphasize the importance of transparency in healthcare.
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Adverse Event Report: This form is used to document any negative outcomes resulting from medical treatment or interventions. Like the Medication Error form, it aims to analyze the causes of the event and improve future patient care. Both are critical for understanding and mitigating risks.
Quality Assurance Report: This document tracks the quality of care provided in a healthcare facility. Similar to the Medication Error form, it assesses compliance with established standards and identifies areas for improvement. Both forms serve as tools for enhancing overall healthcare quality.
Pharmacy Audit Report: This report reviews pharmacy practices and compliance with regulations. Like the Medication Error form, it identifies discrepancies and errors that could affect patient safety. Both documents support accountability and continuous improvement in pharmacy operations.
Root Cause Analysis Report: This document investigates the underlying reasons for an incident. Similar to the Medication Error form, it seeks to understand what went wrong and how to prevent it in the future. Both reports are essential for fostering a culture of safety in healthcare settings.

Free Medication Error File

Medication Error Example

MEDICATION INCIDENT AND DISCREPANCY REPORT FORM

Incident Report #:

MEDICATION INCIDENT AND DISCREPANCY REPORT

1.Use for all medication incidents. Medication discrepancies can be reported at pharmacist’s discretion.

2.The pharmacist discovering the error initiates the report

3.Notify physician and pharmacy manager of all MEDICATION INCIDENTS that could affect the health or safety of a patient

PATIENT INFORMATION

Name:____________________________________

Address:__________________________________

Phone:____________________________________

Sex: _____ DOB:_________________________

Rx #:_____________________________________

PHIN_____________________________________

Error Date:	______________________________				Pharmacist initiating
	Hour	Date	Month	Year	report:	______________________
Discovery Date:	______________________________
	Hour	Date	Month	Year
Drug ordered:
(State: drug/dose/form/route/directions for use)

Medication Incident: an erroneous medication commission or omission that has been subjected upon a patient.

Medication Discrepancy: an erroneous medication commission or omission that has not been released for the patient.

TYPE OF INCIDENT– Patient received drug:
	Incorrect Dose		Incorrect Dosage Form		Incorrect Drug
	Incorrect Generic Selection		Incorrect Patient		Incorrect Strength
	Outdated Product		Allergic Drug Reaction		Incorrect Label/Directions
	Drug Unavailable/Omission		Drug-drug Interaction		Other ________________

______________________________________________________________________________________________

TYPE OF INCIDENT OR DISCREPANCY – Patient did not receive drug:

Prescribing (specify) _______________________________________________________________________

Dispensing (specify) _______________________________________________________________________

Documentation (specify) ____________________________________________________________________

Other (specify) ____________________________________________________________________________

INCIDENT/DISCREPANCY DESCRIPTION

State facts as known at time of discovery. Additional details about the error by the pharmacist involved may be attached to this document.

________________________________________________________________________________________________

DATE:	______________________________	________________________________
	Hour Date Month Year	Signature of Pharmacist:

Page 1 of 2

CONTRIBUTING FACTORS

(To be completed by pharmacist responsible)

	Improper patient identification	 Misread/misinterpreted drug order (include verbal orders)
	Incorrect transcription		Drug unavailable
 Lack of patient counselling			Other

	DATE:	______________________________	__________________
		Hour Date Month Year	Signature
	NOTIFICATION – Complete the following information according to Standards of Practice.
1.		Patient notified:
			___________________________
			Hour		Date	Month	Year
2.		Physician notified: ____	______________________________
		Yes/No	Hour		Date	Month	Year

	SEVERITY
		None		 No change in patient’s condition: no medical intervention
		Minor			required
		Major		 Produces a temporary systemic or localized response: does
					not cause ongoing complications
				 Requires immediate medical intervention
	OUTCOME OF INVESTIGATION

	FOLLOW-UP:
	Problem Identification				Action
		Lack of knowledge			Education provided
		Performance problem			Policy/procedure changed
		Administration problem			System changed
		Other			Individual awareness
					Group awareness
					Other

	RESOLUTION OF PROBLEM THAT RESULTED IN THE ERROR BEING MADE:

	Signature:		Date:		Signature:		Date:
	(Pharmacist filling out the form)				(Pharmacy Manager)

PHARMACY USE ONLY

Page 2 of 2

Understanding Medication Error

What is the purpose of the Medication Error form?

The Medication Error form is designed to document any incidents or discrepancies related to medication. It serves as a tool for pharmacists to report errors that may affect patient safety or health. By using this form, pharmacists can communicate vital information about the incident to the appropriate parties, including physicians and pharmacy managers. This helps ensure that necessary actions are taken to address the issue and prevent future occurrences.

Who is responsible for initiating the report?

The pharmacist who discovers the medication error is responsible for initiating the report. This individual is in the best position to provide accurate details about the incident. It is important that the report is completed as soon as possible after the discovery to ensure that all relevant information is captured and communicated effectively.

What types of medication incidents can be reported using this form?

The form can be used to report a variety of medication incidents. These include, but are not limited to, incorrect doses, incorrect drugs, allergic reactions, and drug interactions. It also covers situations where a patient did not receive a prescribed medication due to issues with prescribing, dispensing, or documentation. Each incident type is categorized to help in identifying and addressing the specific nature of the error.

What steps should be taken after a medication error is reported?

After a medication error is reported, the pharmacist should notify both the patient and the physician about the incident. This communication is crucial for ensuring patient safety and addressing any immediate health concerns. Additionally, an investigation should follow to identify contributing factors and implement corrective actions. These may include education for staff, changes in policies, or adjustments to procedures to prevent similar errors in the future.

Dos and Don'ts

When filling out the Medication Error form, it is crucial to follow certain guidelines to ensure accuracy and clarity. Here are six important dos and don'ts:

Do report all medication incidents immediately.
Do provide complete and accurate patient information.
Do describe the incident clearly, stating facts as known at the time of discovery.
Do notify the physician and pharmacy manager about incidents that could affect patient safety.
Don't leave out any details that may be relevant to the incident.
Don't delay in completing the form; timely reporting is essential.

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