Medication Error Report Form - Illinois Department Of Human Services
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1Illinois Department of Human Services
Division of Developmental Disabilities
Medication Error Report
Directions: In accord with Rule 116, CILA providers must document all medication errors. In addition, all
medication errors for which there is an adverse outcome to the person receiving services must be reported
to the Division of Developmental Disabilities’ Bureau of Quality Management. This form must be completed
for each such error. Adverse outcome errors must be faxed to (217) 782-9444 within 7 calendar days of
discovery. It is not necessary to notify BQM of errors for which there is no adverse outcome. However,
errors for which there is no adverse outcome must be documented, reviewed by the RN-Trainer and
summarized/analyzed on at least a quarterly basis by the agency. If assistance is needed, phone BQM at
(217) 782-9438.
Agency Name:
Telephone #:
Person Receiving Services: _______________________
Date of Error: ______________________________
CILA Address:__________________________________
Date of Discovery:___________________________
City/State/Zip:__________________________________
Discovered by:_____________________________
Medications Involved:
Does the person receiving services independently
administer his/her own medications?
___Yes
___No
Notification:
Supervisor (name):________________________________________ Date:________________ Time:__________
RN-Trainer (name): _______________________________________ Date:________________ Time:__________
Pharmacy (name): ________________________________________ Date:________________ Time:__________
Physician (name): ________________________________________ Date:________________ Time:__________
O.I.G. (name): ______________________________Date:__________Time:__________Case #:_______________
Description of Events:
Contributing Factors:
_____ Unlocked Medications
_____ Lack of Staff Concentration
_____ Emergency Situation
_____ Insufficient Staff
_____ OTC meds purchased
_____ Inexperienced Staff
_____ Transcription incorrect
_____ Pharmacy unavailable
_____ Medication’s not ordered/unavailable
_____ Other (
:
explain)
Medication Error Type:
Staff/Persons Involved:
(Check all that apply)
_____ Wrong Consumer
_____ Unauthorized Staff
_____ Authorized Staff Name:_______________________
_____ Wrong Drug
_____ Med. Change/not trained
_____ Unauthorized Staff Name:_____________________
_____ Wrong Dose
_____ Transcription Error
_____ RN Name:_________________________________
_____ Wrong Time
_____ Pharmacy Error
_____ LPN Name:________________________________
_____ Wrong Route
_____ Documentation Error
_____ MD Name:_________________________________
_____ Wrong Consistency
_____ Omission
_____ Pharmacist Name:___________________________
_____ Wrong Technique
_____ Refusal
_____ Parent/Guardian Name:_______________________
_____ Other (explain):
_____ Other Name:________________________________
Corrective Action Taken:
Additional Action Needed:
____Person served did not require medical intervention.
____Person served required medication attention. (Explain:
)
____Person served required hospitalization. (Explain:
)
____Person served sustained permanent harm. (Explain:
)
____Person served died as a result of this error. (Explain:
)
Form Completed By: (Name) ____________________________ (Title) _________________ (Date)___________
Reviewed by RN-Trainer Signature:________________________ (Date) __________ (Phone)_________________
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