Medication Error Report Form printable pdf download

Medication Error Report Form

Student: _________________________________________________________________________________

DOB: _____________________

School Building: __________________________________________________________________________________ Grade: _____________

Date of Error: ___________________ Medication: __________________________________________________________________________

Medication Dosage: ________________________________ Time to be given: _____________________ Route: _________________________

State Reason For Report: (failure to administer medication to the student, failure to administer medication within the designated time, failure to

administer the correct dosage of medication, failure to administer medication by proper route, failure to administer medication according to

generally accepted standards of practice, administering the wrong medication to the wrong student, administering medication without parent

authorization, administering a prescription medication to a student who does not have a prescription)

Medication Errors DO NOT include: unusual situations or incidents where students refuse to consume or are unable to tolerate medication

administration, lack of supply of medication from the parent, or a medication held by a parent/guardian. Careful notation of these situations should

be made on the back of the medication administration record or incident form, if applicable, and parents/guardian notification per school

procedure.

Action Taken/Intervention:

School Nurse Name (Print): ________________________________________

Notified: _________ Yes __________ No

Date: ____________________ Time: ____________________

Name of Parent/Guardian notified (if applicable):

___________________________________________________ Date and Time: ___________________

Student’s physician notified (if applicable):

___________________________________________________ Date and Time: ___________________

Building Administrator Signature:

___________________________________________________ Date: ___________________________

Witness(s): ______________________________________________

Name of Person Preparing Report (Please Print): ___________________________________________

Signature of Person Preparing Report: _______________________________________ Date: _______

Follow Up Skills Check Completed By School Nurse: __________ Yes __________No

Follow Up Care/Contact: ___________________________________________________________________________________________

________________________________________________________________________________________________________________

Signature of School Nurse Notified/Conducting Skills Check, Follow-Up Care: ________________________________________________

**************************************************************************************************************************************

This is an example of information needed in a medication error report. School determines policies and procedures who will be notified and in what order. The

form should be completed in ink. Do not use “white out”, correction tape, eraser, or pencil to correct recording errors. Draw a single line through the error, record

the correct information, and initial the corrected entry. The completed form is to be sent to the school nurse and a copy delivered to the school administrator to

be placed in a designated location defined by the school.

Medication Error Report Form

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