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)

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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

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