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Medication Safety Event Form
 
Patient Name:   DOB:
ROOM # AT TIME OF INCIDENT:   PT ACCT#:
     
Event Date:    Unknown Event Time:    Unknown
 
Status: Inpatient/Observation Status Home Health/Hospice Spring Creek Resident:
  Emergency Department Infusion center Station: 1    2    3    4
  Outpatient    
 
Type of Event: Medication Event Medication Near Miss
  Adverse Drug Reaction  
 

Describe the event and the patient/resident outcome if known (include such information as name dose/route of the medication(s) involved, intervention(s) taken, increased monitoring if needed, or difference between written order and what was administered.
NOTIFICATIONS:
Physician: No Yes Dr.  Date: Time:
 
Director/Supervisor: No Yes              Date: Time:
 
Significant Other: No Yes                      Date: Time:
 
Risk Manager (if event caused significant, immediate harm or death)   No    Yes
   Date:   Time:    
Contributing Factor(s) (check all that apply)
Wrong patient Incorrect/absent 24 hour verification Pump off/setting incorrect
Wrong medication Distraction(s) Pump tubing clamped
Wrong/Missed/Extra dose Poor lighting Calculation error
Wrong route Abbreviation error Incorrect drug label
Wrong time Computer entry error/omission Look alike/sound alike medication
Known allergy to medication Handwriting illegible/unclear Pump malfunction
Incorrect transcription Stocked wrong drug/dose Other:
     
Is there a change which could be made at MCCH which would prevent this event from occurring in the future?
 
Report completed by: Date: Time:

Anonymous submission
 

Click the Submit button below to send the form to the appropriate location.