Medication Error Report
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1Medication Error Report
Date of Report:
Resident Name:
DOB:
Room #
Primary Care Physician
Phone:
DESCRIPTION OF ERROR
Date of Error
Time of Error :
am
Medication as ordered:
pm
Description of error ( include medication, dose, route, and time administered)
Outcome to resident and care provided
Physician notified?
Name:
Date:
Time:
am
No
Yes
pm
Physicians Instructions:
If No, explain
Administrator Notified?
Name:
Date:
Time:
am
No
Yes
pm
If No, explain
Pharmacy Notified?
Name:
Date:
Time:
am
No
Yes
pm
If No, explain
Family/Responsible Party Notified?
Name:
Date:
Time:
am
No
Yes
pm
If No, explain
Summary of Error
Type of Error
Reason for Error
Wrong dose
Drug orderd but not administered
Transcription error
Failure to identify resident
Wrong route
Drug administered without physicians orders
Misread error
Pharmacy error
Wrong medication
Failure to follow manufactures specifications and
Miscalculated dose
Poor lighting and environment
accepted professional standards
Wrong dose form
Wrong time
Other:
Mismeasured dose
Self medication error
Corrective actions taken
Measure taken to prevent reocurrence
Priority Policy
Signature
Title
Date
1.
Person making error
2.
Person correcting error
3.
Attending physician
4.
Pharmacist
5.
Administrator/Director
LTC Consulting: Medication Error Report
Page 1
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