Prescription Fulfillment Accuracy Report Form
Report and assess the accuracy of prescription fulfillment to support quality improvement in pharmacy operations.
Reporter Full Name
*
First Name
Last Name
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pharmacy Location
*
Prescription Number (Rx#)
*
Patient Initials (do not use full name)
*
Date Prescription Was Filled
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role of Reporter
*
Please Select
Pharmacist
Pharmacy Technician
Intern
Other
Was the prescription filled accurately?
*
Yes
No
If an error occurred, select the type(s) of error identified:
Wrong drug dispensed
Incorrect strength or dosage
Wrong quantity
Incorrect labeling
Patient information error
Other
Please rate the overall accuracy of the prescription fulfillment process:
*
1
2
3
4
5
Describe the error and corrective actions taken (if applicable):
Staff members involved in the fulfillment process (initials only):
Actions implemented to prevent similar errors in the future:
Submit Report
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