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Download Medication Error Template

The Medication Error Form is a tool used to report any medication incidents or discrepancies that occur in a healthcare setting. This form helps ensure that healthcare professionals can document errors and take necessary actions to protect patient safety. By providing clear information about the incident, it supports better communication among pharmacists, physicians, and other staff involved in patient care.

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Content Overview

The Medication Error form is a crucial tool for ensuring patient safety in healthcare settings. This form is designed to document any medication incidents or discrepancies that occur during the prescribing, dispensing, or administration of medications. When a pharmacist discovers an error, they are responsible for initiating the report, which includes important details about the incident, such as the patient's information, the nature of the error, and the actions taken in response. It is essential to notify both the physician and the pharmacy manager about any incidents that could impact a patient's health. The form categorizes the type of incident, whether it involves an incorrect dose, wrong drug, or a patient not receiving their prescribed medication. Additionally, it allows pharmacists to identify contributing factors that may have led to the error, such as miscommunication or lack of patient counseling. By documenting these incidents, healthcare professionals can work towards preventing future occurrences and improving overall patient care.

Key takeaways

Filling out and utilizing the Medication Error form is a critical process in ensuring patient safety and improving pharmacy practices. Here are some key takeaways to keep in mind:

Comprehensive Reporting: This form should be used for all medication incidents. It allows for thorough documentation of any discrepancies, ensuring that all relevant information is captured.
Initiation by Pharmacist: The pharmacist who discovers the error is responsible for initiating the report. This personal accountability helps maintain clarity regarding who identified the issue.
Notification is Essential: It is crucial to notify both the physician and pharmacy manager about any incidents that could impact a patient's health or safety. This step ensures that appropriate actions can be taken promptly.
Detailed Incident Description: When describing the incident, provide all known facts at the time of discovery. Additional details can be attached to the report, which may aid in understanding the context of the error.
Contributing Factors: The form includes a section for identifying contributing factors. This helps in recognizing patterns or systemic issues that may need to be addressed to prevent future errors.
Follow-Up Actions: After the investigation, it is important to document any resolutions or changes made in response to the incident. This may include education, policy changes, or system improvements.

By adhering to these guidelines, pharmacy professionals can work towards enhancing patient safety and minimizing the risk of medication errors.

Guide to Writing Medication Error

Completing the Medication Error form is an important step in ensuring patient safety and improving pharmacy practices. This process requires careful attention to detail, as accurate reporting can help identify areas for improvement and prevent future incidents. Below are the steps to fill out the form effectively.

Begin by locating the Incident Report # section at the top of the form and fill in the appropriate number.
In the PATIENT INFORMATION section, provide the patient's name, address, phone number, sex, date of birth, prescription number, and PHIN.
Record the Error Date and the date the pharmacist is initiating the report.
Indicate the Drug ordered by specifying the drug name, dose, form, route, and directions for use.
Choose the type of incident by marking the appropriate box under TYPE OF INCIDENT – Patient received drug. Options include incorrect dose, incorrect drug, allergic reaction, etc.
If the patient did not receive the drug, check the relevant box under TYPE OF INCIDENT OR DISCREPANCY – Patient did not receive drug and provide any necessary specifications.
In the INCIDENT/DISCREPANCY DESCRIPTION section, clearly state the facts as known at the time of discovery. Include any additional details that may be relevant.
Sign and date the form in the designated area for the pharmacist initiating the report.
Complete the CONTRIBUTING FACTORS section by marking any factors that contributed to the incident.
Fill out the NOTIFICATION section, indicating whether the patient and physician have been notified, along with the corresponding dates and times.
Select the appropriate severity level from the options provided.
Complete the OUTCOME OF INVESTIGATION FOLLOW-UP section by identifying the problem and any actions taken to resolve it.
Finally, ensure that both the pharmacist and pharmacy manager sign and date the form in the designated areas.

After completing the form, it should be submitted according to the pharmacy's procedures. This ensures that the incident is documented and addressed appropriately, contributing to a safer environment for patients and staff alike.

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Form Preview Example

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

When dealing with medication errors, it is important to have a comprehensive set of documents to ensure proper reporting and follow-up. Below is a list of forms and documents that are often used alongside the Medication Error form. Each serves a specific purpose in the process of addressing medication incidents.

Incident Report Form: This document captures the details of any incident that occurs within the healthcare setting, including medication errors. It helps in documenting what happened, when, and who was involved.
Patient Safety Report: This report focuses on safety issues affecting patients, including medication errors. It aims to identify trends and areas for improvement in patient care.
Chick Fil A Job Application Form: This form is essential for candidates interested in joining the team at Chick-fil-A. Completing the application is the first step in the hiring process, as outlined here: https://smarttemplates.net/fillable-chick-fil-a-job-application.
Pharmacy Audit Report: This form is used to review pharmacy operations and compliance with regulations. It helps identify areas where medication errors may arise due to systemic issues.
Root Cause Analysis (RCA) Report: An RCA report investigates the underlying reasons for a medication error. It aims to prevent future occurrences by addressing the root causes.
Medication Administration Record (MAR): This record tracks all medications administered to a patient. It is essential for verifying whether the correct medication was given at the right time.
Patient Consent Form: This document ensures that patients are informed about their medications and any potential risks. It is crucial for maintaining transparency and trust.
Pharmacist Intervention Form: This form is used when a pharmacist intervenes in a medication-related issue. It documents the intervention and its outcome, providing valuable information for future reference.
Follow-Up Action Plan: After a medication error, this plan outlines steps to address the incident and prevent recurrence. It may include staff training or policy changes.

Using these documents effectively can enhance patient safety and improve the overall quality of care. Each form plays a role in a larger system designed to prevent medication errors and promote accountability within healthcare settings.