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Fill in a Valid Medication Error Form

The Medication Error Form is a crucial tool used to document incidents related to medication errors and discrepancies. This form is initiated by the pharmacist who discovers the error and is essential for notifying relevant parties, including physicians and pharmacy managers, about any incidents that could impact patient safety. By systematically reporting these errors, healthcare providers can enhance patient care and prevent future occurrences.

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Example - Medication Error Form

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	Outdated Product		Allergic Drug Reaction		Incorrect Label/Directions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:

Page 1 of 2

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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Documents used along the form

In addition to the Medication Error form, various other documents play crucial roles in the medication management process. These documents help ensure patient safety, facilitate communication among healthcare providers, and maintain compliance with regulatory standards. Below is a list of common forms and documents that are often used in conjunction with the Medication Error form.

Incident Report Form: This form captures details about any incident that occurs within a healthcare setting, not limited to medication errors. It helps in identifying trends and areas for improvement.
Patient Consent Form: This document secures a patient's permission before administering medication or treatment. It outlines potential risks and benefits, ensuring that patients are informed.
Medication Administration Record (MAR): This record tracks all medications administered to a patient, including dosages and times. It serves as a vital tool for healthcare providers to ensure accurate medication delivery.
Pharmacy Audit Form: Used during pharmacy audits, this form assesses compliance with medication dispensing protocols and identifies areas needing improvement.
Retirement Option Election Form: The NYCERS F552 form allows Tier 1 and Tier 2 members to select their preferred pension payment option, impacting financial security for retirees and beneficiaries. For more details, visit https://nytemplates.com/blank-nycers-f552-template/.
Medication Reconciliation Form: This document is used to compare a patient's medication orders to all medications the patient has been taking. It aims to prevent discrepancies during transitions of care.
Adverse Drug Reaction Report: This form is used to document any negative effects a patient experiences from a medication. It helps in tracking the safety and efficacy of drugs.
Medication Safety Assessment: This assessment evaluates the safety practices in place within a pharmacy or healthcare facility, identifying potential risks related to medication errors.
Quality Assurance Report: This report documents the outcomes of quality checks within a pharmacy, focusing on medication safety and adherence to established protocols.
Training and Competency Assessment Form: This form assesses the training and competency of pharmacy staff in medication management, ensuring they are equipped to handle medications safely.
Patient Education Materials: These documents provide patients with information about their medications, including usage, side effects, and interactions, promoting informed patient participation in their care.

Utilizing these forms and documents alongside the Medication Error form enhances the overall medication management process. They contribute to better patient outcomes by fostering a culture of safety and accountability within healthcare settings.