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Fill in a Valid Medication Error Form

The Medication Error Form is a critical document used to report incidents and discrepancies related to medication. It serves as a tool for pharmacists to initiate reporting when an error has been discovered, ensuring that all relevant parties, including physicians and pharmacy managers, are notified. This form helps to maintain patient safety by documenting the nature of the error and the circumstances surrounding it.

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MEDICATION INCIDENT AND DISCREPANCY REPORT FORM

Incident Report #:

MEDICATION INCIDENT AND DISCREPANCY REPORT

1.Use for all medication incidents. Medication discrepancies can be reported at pharmacist’s discretion.

2.The pharmacist discovering the error initiates the report

3.Notify physician and pharmacy manager of all MEDICATION INCIDENTS that could affect the health or safety of a patient

PATIENT INFORMATION

Name:____________________________________

Address:__________________________________

Phone:____________________________________

Sex: _____ DOB:_________________________

Rx #:_____________________________________

PHIN_____________________________________

Error Date:	______________________________				Pharmacist initiating
	Hour	Date	Month	Year	report:	______________________
Discovery Date:	______________________________
	Hour	Date	Month	Year
Drug ordered:
(State: drug/dose/form/route/directions for use)

Medication Incident: an erroneous medication commission or omission that has been subjected upon a patient.

Medication Discrepancy: an erroneous medication commission or omission that has not been released for the patient.

TYPE OF INCIDENT– Patient received drug:
	Incorrect Dose		Incorrect Dosage Form		Incorrect Drug
	Incorrect Generic Selection		Incorrect Patient		Incorrect Strength
	Outdated Product		Allergic Drug Reaction		Incorrect Label/Directions
	Drug Unavailable/Omission		Drug-drug Interaction		Other ________________

______________________________________________________________________________________________

TYPE OF INCIDENT OR DISCREPANCY – Patient did not receive drug:

Prescribing (specify) _______________________________________________________________________

Dispensing (specify) _______________________________________________________________________

Documentation (specify) ____________________________________________________________________

Other (specify) ____________________________________________________________________________

INCIDENT/DISCREPANCY DESCRIPTION

State facts as known at time of discovery. Additional details about the error by the pharmacist involved may be attached to this document.

________________________________________________________________________________________________

DATE:	______________________________	________________________________
	Hour Date Month Year	Signature of Pharmacist:

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CONTRIBUTING FACTORS

(To be completed by pharmacist responsible)

	Improper patient identification	 Misread/misinterpreted drug order (include verbal orders)
	Incorrect transcription		Drug unavailable
 Lack of patient counselling			Other

	DATE:	______________________________	__________________
		Hour Date Month Year	Signature
	NOTIFICATION – Complete the following information according to Standards of Practice.
1.		Patient notified:
			___________________________
			Hour		Date	Month	Year
2.		Physician notified: ____	______________________________
		Yes/No	Hour		Date	Month	Year

	SEVERITY
		None		 No change in patient’s condition: no medical intervention
		Minor			required
		Major		 Produces a temporary systemic or localized response: does
					not cause ongoing complications
				 Requires immediate medical intervention
	OUTCOME OF INVESTIGATION

	FOLLOW-UP:
	Problem Identification				Action
		Lack of knowledge			Education provided
		Performance problem			Policy/procedure changed
		Administration problem			System changed
		Other			Individual awareness
					Group awareness
					Other

	RESOLUTION OF PROBLEM THAT RESULTED IN THE ERROR BEING MADE:

	Signature:		Date:		Signature:		Date:
	(Pharmacist filling out the form)				(Pharmacy Manager)

PHARMACY USE ONLY

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Document Information

Fact Name	Description
Purpose of the Form	This form is used for reporting all medication incidents and discrepancies that occur in a pharmacy setting.
Initiation of Report	The pharmacist who discovers the medication error is responsible for initiating the report.
Notification Requirements	All medication incidents that may impact patient health or safety must be reported to the physician and pharmacy manager.
Patient Information Section	The form requires essential patient details such as name, address, phone number, sex, date of birth, and prescription number.
Types of Incidents	Incidents can include incorrect dosage, wrong drug, allergic reactions, and more. Each type must be clearly indicated on the form.
Severity Levels	The form includes a section to classify the severity of the incident, ranging from no change in condition to requiring immediate medical intervention.
Contributing Factors	Pharmacists must identify contributing factors such as improper patient identification or misinterpretation of drug orders.
Follow-Up Actions	After an incident, actions may include providing education, changing policies, or improving system processes to prevent future errors.
State-Specific Regulations	For state-specific forms, it is essential to reference the applicable governing laws related to medication error reporting.

Medication Error - Usage Guidelines

Completing the Medication Error form is an important step in ensuring patient safety and addressing medication discrepancies. This process requires careful attention to detail and accuracy. After filling out the form, it will be reviewed by the relevant parties, including the pharmacy manager, to determine the necessary actions and follow-up procedures.

Locate the form: Obtain the Medication Incident and Discrepancy Report Form from your pharmacy's designated area.
Fill in the incident report number: Write down the Incident Report # at the top of the form.
Provide patient information: Enter the patient's name, address, phone number, sex, date of birth (DOB), prescription number (Rx #), and patient health identification number (PHIN).
Document the error date: Indicate the date the medication error occurred.
Identify the pharmacist: Write the name of the pharmacist initiating the report and the date of discovery.
Specify the drug ordered: Clearly state the drug, dosage, form, route, and directions for use.
Select the type of incident: Mark the appropriate box to indicate whether it was a medication incident or discrepancy, and provide details if necessary.
Detail the type of incident or discrepancy: Indicate whether the patient received the drug incorrectly or did not receive the drug, specifying the nature of the issue.
Describe the incident: Provide a detailed account of the incident as known at the time of discovery. Include any relevant facts or attach additional details if necessary.
Complete contributing factors: Check all applicable factors that contributed to the error.
Document notifications: Record the date and time when the patient and physician were notified about the incident.
Assess severity: Mark the appropriate level of severity regarding the patient's condition.
Outline follow-up actions: Specify any actions taken to resolve the problem and improve processes to prevent future occurrences.
Sign the form: Ensure that both the pharmacist filling out the form and the pharmacy manager sign and date the document.

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Dos and Don'ts

When filling out the Medication Error form, it is crucial to adhere to best practices to ensure accuracy and compliance. Below are essential dos and don’ts:

Do use the form for all medication incidents, regardless of their severity.
Do ensure that the pharmacist discovering the error initiates the report.
Do promptly notify the physician and pharmacy manager of any incidents that could impact patient safety.
Do provide clear and concise details about the incident in the description section.
Don't omit any relevant patient information, such as name and contact details.
Don't delay in reporting the incident; timely notification is essential.
Don't forget to document the contributing factors accurately.
Don't leave any sections of the form incomplete; ensure all fields are filled out.

Common mistakes

Incomplete Patient Information: Failing to provide all necessary details about the patient can lead to confusion and complicate follow-up actions. Ensure that the patient's name, address, phone number, sex, date of birth, and relevant prescription numbers are fully filled out.
Neglecting to Document the Incident Date: It's crucial to accurately record the date of the error. Omitting this information can hinder the investigation process and make it difficult to track patterns or recurring issues.
Misclassifying the Type of Incident: Selecting the wrong type of incident can lead to misunderstandings and mismanagement of the situation. Take the time to carefully consider whether the error was a medication incident or a discrepancy before making a selection.
Inadequate Description of the Incident: Providing vague or insufficient details in the description section can leave critical gaps in understanding what went wrong. Be thorough and clear about the facts known at the time of discovery.
Failure to Notify Relevant Parties: Not informing the physician or pharmacy manager about the incident can have serious consequences for patient safety. Always ensure that notifications are made promptly and documented appropriately.

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