Medication Error Report Form
Incident Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
Hour Minutes
AM
PM
AM/PM Option
Location
Hospital Ward
Emergency room
Surgery
Labor and Delivery
Out-patient clinic
Pharmacy
Dental Clinic
When was it discovered?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Type
Wrong patient
Incorrect dosage
Wrong drug of administration
Wrong route of administration
Incorrect time of administration
Incorrect formula
Expired or incorrect technique performed
Other
Please provide more explanation about the incident and how it happened.
Ordered Medication
Rows
Intended to Administer
Error in Administration
Drug Name (Brand)
Drug Name (Generic)
Dosage
Route (Oral, Sublingual, IM, IV, Inhalation, Topical, Other)
Directions for Use
What is the outcome or result of the incident?
Patient was not harmed
Patient was not affected
Patient need monitoring
Patient required treatment
Patient required more hospitalization time
Patient was permanently harmed
Patient needed emergency treatment
Patient died
Other
Please provide an explanation in paragraph format about the outcome of the incident.
What are the possible reasons or contributor factors why did this incident happened?
Missing or incorrect information
Drug details are incorrect
Miscommunication between health care workers
Drug label and packaging issues
Incorrect drug solution or content
Staffing issues
Environmental factors
Lack of education
Lack of training
Other
Please explain more in details about the options you selected above (previous question).
What are the things that health care workers should do in order to prevent this type of incident?
For Authorize Use Only
Â
Patient ID
Patient Name
First Name
Last Name
Medical Diagnosis
Age
Gender
Male
Female
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporter's Name
First Name
Last Name
Position/Title
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Â
Â
Print Form
Submit
Should be Empty: