Pharmacy Medication Error Log Form
Use this form to record and review medication errors that occur in the pharmacy. Please provide clear and accurate details for each incident.
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Medication Name
*
Type of Error
*
Please Select
Wrong medication dispensed
Incorrect dosage
Wrong patient
Incorrect labeling
Missed dose
Other
Brief Description of the Error
*
How was the error discovered?
*
Please Select
Self-reported
Patient reported
Colleague reported
Routine check
Other
Outcome or Consequences
*
Please Select
No harm
Near miss (caught before reaching patient)
Required monitoring/intervention
Temporary harm
Serious harm
Other
Actions Taken to Address the Error
*
Staff Role(s) Involved (do not use names)
*
Pharmacist
Pharmacy Technician
Pharmacy Assistant
Other
Location of Incident
Please Select
Dispensing area
Storage area
Consultation area
Other
Additional Comments (optional)
Submit Error Log
Should be Empty: