← Medication Error Reporting

Medication Error Report

Step 1 of 6

Important Notice

This form should be completed for all medication errors, including near misses. All information will be kept confidential and used for quality improvement purposes only. Report immediately if patient harm has occurred.

Step 1: Event Information

Event Date & Time *

Discovery Date & Time *

Reporter Name *

Reporter Role *

Department/Unit Where Error Occurred *

Error Severity *

Step 2: Patient Information

Medical Record Number (MRN)

Patient Age

Patient Gender

Patient Weight (kg)

Primary Diagnosis

Relevant Medical History/Allergies

Step 3: Medication Involved

Medication Name *

Strength/Concentration

Dosage Form

Prescribed Dose

Actual Dose Given

Prescribed Route

Actual Route Used

Prescribed Frequency

Actual Frequency

Step 4: Error Classification

Stage of Medication Process *

Prescribing (Physician ordering) Transcribing (Order entry/copying) Dispensing (Pharmacy preparation) Administering (Giving to patient) Monitoring (Follow-up care) Other

Type of Medication Error *

Wrong medication Wrong dose (overdose/underdose) Wrong route of administration Wrong time/frequency Wrong patient Omission (missed dose) Duplication (extra dose) Contraindicated medication Drug-drug interaction Medication given despite known allergy Improper preparation/compounding Labeling error Improper storage Other

Step 5: Event Description

Detailed Description of the Event *

How was the error discovered?

Routine monitoring Patient complaint Staff observation Family notification Laboratory result Other

Contributing Factors (Check all that apply)

High workload/time pressure Inadequate staffing Poor communication Inadequate training Interruptions/distractions Similar drug names Similar packaging/appearance Computer/system failure Staff fatigue Equipment malfunction

Step 6: Actions Taken & Prevention

Immediate Actions Taken *

Patient Outcome/Clinical Effects

Was the patient/family notified?

Yes No Not Applicable

Recommendations to Prevent Recurrence

Follow-up Required?

Priority Level

Report Submitted Successfully!

Report ID: MEH-2025-001

Your medication error report has been submitted to the Patient Safety Team. You will receive confirmation within 24 hours.

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