1. The employee discovering a medication incident shall complete sections 1,2,3, and 4. The report shall be forwarded to the immediate supervisor.
2. The supervisor shall investigate the incident and complete the report. Section 5 may be completed by the physician or the supervisor.
3. The completed report should be forwarded to Risk Management within 5 business days of the incidents.
|2.||DESCRIBE WHAT HAPPENED (details if possible):|
|3.||Error resulted in:
- caught by
- No harm or increased monitoring but no harm.
- Change in vital signs, potential for, or treatment with another drug, temporary harm or increased length of stay.
- Permanent patient harm, significant temporary harm or other need for invasive treatment (*see note below).
- Near death or death (*see note below).
* If you have checked category 3 or 4 , contact the on-site supervisor or CAC immediately.
|4.||MD notified ?||Patient
Affairs notified (630-6676)?
Risk Management notified (630-6425)?
|MD Name :|
|Signature of person completing report:||Date:||Phone number:|