Utah Medication Error Report Form
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2UTAH MEDICATION ERROR REPORT FORM
A medication error is defined as failure to administer the prescribed medication to the right student, at the right
time, the right medication, the right dose or the right route. The person who administered the medication should
complete this form and turn it in to the school nurse or school administrator. This form is not required if Local
Education Agency (LEA) has developed their own Error or Incident form.
Date/Time:
Prepared by:
School District:
School:
Date:
Student Name:
Student DOB:
Teacher/Grade:
Medication Name:
Dose Ordered:
Time Ordered:
Licensed Prescriber:
Phone:
Parent/Guardian:
Phone:
TYPE OF ERROR (Check all that apply)
Wrong student
St
Student on order:
Student given:
Wrong Medication
Medication ordered:
Medication given:
Wrong Dosage
Dosage ordered:
Dosage given:
Wrong Time
Time ordered:
Time given:
Wrong Route
Route ordered:
Route given:
Medication not available
Student refusal
Medication wasted
Expired Medication
Omitted dose(s):
Possible adverse reaction
Describe:
Other:
Explain:
Narrative description of error (use back of form if necessary):
ACTION TAKEN
Student transported by EMS?
No
Yes, Location:
Persons notified:
Licensed Prescriber Notified:
Date Notified:
Time Notified:
Yes
No
Parent/Guardian Notified:
Date Notified:
Time Notified:
Yes
No
School Administrator Notified:
Date Notified:
Time Notified:
Yes
No
School Nurse Notified:
Date Notified:
Time Notified:
Yes
No
FOLLOWUP INFORMATION
Narrative of follow up:
SIGNATURES
Individual preparing report:
Date:
School Nurse:
Date:
Administrator:
Date:
3/13/2017 UDOH M-4
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