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hospitalization and invasive intervention> ‫□اﻟﺒﻘﺎء ﻓﻲ اﻟﻤﺴﺘﺸﻔﻰ أو اﻟﺘﺪﺧﻞ اﻟﺠﺮاﺣﻲ‬
Name: ………… ………………………………………………………...………………………………………….:‫اﻻﺳﻢ‬

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Address:………………………………………………………………………………………………………:t§ª¦Htf|¦H
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Management of Pharmaceutical care tUUUhU¦UUUhU¦HtUUgpUUUUU¦HJQHOF
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Product name (brand & generic) : : (‫اﺳﻢ اﻟﻤﺴﺘﺤﻀﺮ )اﻟﻌﻠﻤﻲ واﻟﺘﺠﺎري‬
Dosage form : : ±¬µh¦H¥¤¦H
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Batch No : : t§hw¦H¨ Q
Mfg & Exp. date : :th~¶¦HDpfw¬HgQpv
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Comparison to Formulary agents including: therapeutic advantages over drugs currently on formulary/ safety
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Comparative Therapy:
Generic Name Dose Cost/ Unit Usage in Total Cost
(Manufacturer) Previous
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Recommendations:
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Physician Nurse Pharmacist Other: ________________________________

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Cream/Ointment/Gel/Paste Eye/ Ear/ nose Syringe
Aerosol/Inhalation/Drops Inhalation/aerosol Bottle
Injectionectable (IV/IM/ET/SC) Injectionectable (IV/IM/IT/SC) Single Dose Vial/ Ampoule
Suppository Topical Skin/ Rectal IV Piggy Bag
Others: _______________________________ Other: ________________________________ Intravenous Solution
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Improper Dose (over, under or extra Wrong rate Wrong Patient
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_______________________________
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_______________________________________________________________________________________________________
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Error reached the patient and required monitoring.
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Error reached the patient and resulted in temporary harm that required intervention.
Error reached the patient and contributed to patient’s death or morbidity (Immediately notify the Sentinel Event Committee in case patient died)
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_______________________________________________________________________________________________________
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Action taken complete Action taken incomplete Action taken not documented
Report forwarded/referred to: __________________________________________________________________
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