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 |
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Hour |
Date |
Month |
Year |
report: |
______________________ |
Discovery Date: |
______________________________ |
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Hour |
Date |
Month |
Year |
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Drug ordered: |
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(State: drug/dose/form/route/directions for use) |
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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: |
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Incorrect Dose |
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Incorrect Dosage Form |
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Incorrect Drug |
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Incorrect Generic Selection |
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Incorrect Patient |
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Incorrect Strength |
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Outdated Product |
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Allergic Drug Reaction |
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Incorrect Label/Directions |
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Drug Unavailable/Omission |
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Drug-drug Interaction |
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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: |
______________________________ |
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Hour Date Month Year |
Signature of Pharmacist: |
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