Medication Disbursement Incident Report
Report and document incidents related to medication disbursement to ensure patient safety and continuous improvement.
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
*
Staff Involved
*
First Name
Last Name
Patient Initials or ID (do not use full name or sensitive ID numbers)
*
Medication Name
*
Dosage
*
Route of Administration
*
Please Select
Oral
Intravenous (IV)
Intramuscular (IM)
Subcutaneous
Topical
Other
Type of Incident
*
Wrong patient
Wrong medication
Wrong dose
Wrong route
Missed dose
Late administration
Other
Describe the Incident
*
Contributing Factors (select all that apply)
Staffing issues
Communication breakdown
Labeling/packaging issue
Environmental factors
Distraction/interruption
Other
Immediate Actions Taken
*
Recommendations to Prevent Future Incidents
Name of Reporter
*
First Name
Last Name
Signature of Reporter
*
Submit Report
Submit Report
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