Get Document

Free Medication Error PDF Form

The Medication Error Form is a crucial document used to report any medication incidents or discrepancies that may affect patient safety. This form is initiated by the pharmacist who discovers the error and serves to notify both the physician and pharmacy manager. Properly filling out this form is essential for ensuring patient safety and improving pharmacy practices.

To report a medication incident, please fill out the form by clicking the button below.

Get Document

Outline

When it comes to patient safety in healthcare, addressing medication errors is of paramount importance. The Medication Error form serves as a vital tool for documenting incidents related to medication discrepancies, ensuring that healthcare professionals can report and analyze errors effectively. This form is initiated by the pharmacist who discovers the error, allowing for a structured approach to reporting. Key details are captured, including patient information, the nature of the medication error, and the specific type of incident or discrepancy. For example, it distinguishes between situations where a patient received the wrong medication or dosage and instances where a patient did not receive their prescribed medication at all. Additionally, the form requires the pharmacist to note contributing factors that may have led to the error, such as miscommunication or improper patient identification. Following the incident, the form also outlines necessary notifications to the patient and physician, emphasizing the importance of transparency in healthcare. Finally, the form facilitates an investigation into the error, documenting the outcomes and any actions taken to prevent similar occurrences in the future. By using this form, healthcare providers can enhance their practices and ultimately improve patient safety.

Find Popular PDFs

Amendment to Trust - Each party should keep their own copy of the signed amendment.

When engaging in the sale of a dirt bike in New York, it is essential to utilize the New York Dirt Bike Bill of Sale form, as it provides a clear and legal record of the transaction, which can be vital for future ownership verification. To aid in this process, you can find a comprehensive guide and download the necessary documents at vehiclebillofsaleform.com/dirt-bike-bill-of-sale-template/new-york-dirt-bike-bill-of-sale-template/, ensuring that you complete the sale with all required details and peace of mind.

Welder Performance Qualification Record - Welders must keep accurate records of their qualification results.

Socialsecurity611 - Applicants can help the SSA better understand their financial need with the SSA-44.

Key takeaways

Filling out and using the Medication Error form is a critical process for ensuring patient safety and improving pharmacy practices. Here are key takeaways to keep in mind:

Use for All Medication Incidents: This form is required for documenting all medication incidents. Medication discrepancies can be reported at the pharmacist's discretion.
Initiation of Report: The pharmacist who discovers the error must initiate the report promptly to ensure accurate documentation.
Notify Relevant Parties: It is essential to notify both the physician and pharmacy manager about all medication incidents that could impact patient health or safety.
Patient Information: Complete all patient information fields accurately, including name, address, phone number, sex, date of birth, and prescription number.
Type of Incident: Clearly indicate the type of incident or discrepancy. Specify whether the patient received the wrong medication or did not receive the prescribed drug.
Incident Description: Provide a detailed description of the incident as known at the time of discovery. Attach additional details if necessary.
Contributing Factors: The pharmacist responsible should identify contributing factors to the incident, such as improper patient identification or misinterpretation of drug orders.
Notification Records: Document notifications made to the patient and physician, including date and time, to maintain a clear communication trail.
Follow-Up Actions: Outline any follow-up actions taken as a result of the incident, such as providing education or changing policies to prevent future errors.

Adhering to these guidelines will help ensure that medication errors are managed effectively and that patient safety remains a top priority.

Form Preview 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