Make your own free website on



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: 



Medication ordered:

Medication given:

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 :
5. MD's comments:
Signature of person completing report: Date:  Phone number: