Ade And Near Miss Incident Classification Form

ADVERTISEMENT

DATAFORM 5
ADE and Near Miss Incident Classification Form
1. Study ID Number:
____ ____ ____ ____
1. Rx ID Number:
____ ____ ____ ____
2. Case Number:
____ ____ ____ ____ ____
3. Reviewer Initials:
____ ____ ____
4. Classification of incident
____
1. ADE
(Choose only one)
2. Near Miss
3. Medication Error
4. Exclusion
5. Confidence regarding above judgement?
____
1. Little or no evidence
2. Modest confidence
3. Medium confidence
4. Strong confidence
5. Very certain confidence
6. Severity of ADE or PADE
____
1. Fatal
(Choose only one)
2. Life-threatening
3. Serious
4. Significant
5. Not an ADE or Near Miss
7.
Preventability—Implicit
____
1. Error intercepted
(choose only one)
2. Definitely preventable
3. Probably preventable
4. Probably not preventable
5. Definitely not preventable
Page 1 of 3
6/6/05
Dataform 5: ADE and Near Miss Incident Classification Form
Version 5.0

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 3