Medication Dispensing Error Report
Please use this form to report and document any medication dispensing errors to support patient safety and quality improvement.
Your Full Name
*
First Name
Last Name
Your Role or Position
*
Please Select
Nurse
Pharmacist
Physician
Technician
Other
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., ward, department)
*
Patient Initials (do not use full name or ID)
*
Medication Name
*
Dose and Route (e.g., 10mg oral)
*
Type of Dispensing Error
*
Wrong medication
Wrong dose
Wrong route
Wrong patient
Omission (missed dose)
Other
Describe the Error and How It Occurred
*
Contributing Factors (select all that apply)
Look-alike/sound-alike medication
Workload/staffing issues
Communication breakdown
Labeling/packaging issue
Environmental factors
Other
Immediate Actions Taken
Recommendations to Prevent Future Errors
Submit Report
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