Med error form

MEDICATION INCIDENT REPORT

Instructions:

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.

1.	Incident Date: Incident Time: Report Date:	Incident Location: Outpatient: Clinic Inpatient: Area Long term care		Medication ordered: Medication given:
2.	DESCRIBE WHAT HAPPENED (details if possible):
3.	Error resulted in: Did not reach patient - caught by patient nurse pharmacist physician other Category 1 - No harm or increased monitoring but no harm. Category 2 - Change in vital signs, potential for, or treatment with another drug, temporary harm or increased length of stay. Category 3 - Permanent patient harm, significant temporary harm or other need for invasive treatment (see note below). Category 4 - 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 ? yes no		Patient Affairs notified (630-6676)? Yes No Risk Management notified (630-6425)? Yes No
	Date/Time
	MD Name :
5.	MD's comments:
Signature of person completing report:			Date:	Phone number: