Medication Incident Report Form-0007A

MEDICATION INCIDENT REPORT

FORM-0007A
PLEASE REFER TO THE "RESPONDING TO A MEDICATION ERROR FLOWCHART" BELOW.
Resident's Name*

First NameLast Name
Date incident identified:*

DayMonthYear
DateHourMinutesAM/PM Option
Date and time incident occurred:*

DayMonthYear
DateHourMinutesAM/PM Option
Describe the incident and what happened:
Describe how the incident was managed:
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Date reported to management/service provider:

DayMonthYear
Date
Describe any corrective actions planned or taken to prevent a recurrence:
Name of staff reporting issue:*

First NameLast Name
Dealing with and recording a medication incident

Service providers are responsible for monitoring patterns of medication incidents and errors.

This responsibility includes reporting errors to the relevant medical practitioner, ensuring the advice of the medical practitioner is followed in addressing an error, documenting any errors on the resident’s medication records and ensuring processes are in place to minimise the risk of continued or future errors.
- where the medical practitioner’s advice or instruction involves a change to the original medication schedule, the advice or instruction is expected to be in writing.
- where it cannot be provided in writing, it should be verbally confirmed by the medical practitioner with either the service provider or staff member. A second service provider or staff member should repeat the instruction back to the medical practitioner for confirmation of accuracy, and request confirmation from the medical practitioner in writing as soon as possible thereafter.
- a written record of the verbal advice from the medical practitioner should be made as soon as possible by staff members in the resident’s medication record and in staff communication notes used within the service. If a new prescription is required, the medical practitioner’s oral instruction must be to the pharmacist who will be dispensing the medication.
MANAGER USE ONLY

MANAGER INVESTIGATION AND RESPONSE
Manager's Name:

First NameLast Name
What is the level of risk:

Very HighHighMediumLow
What led up to the incident taking place?
What control measures will be put in place to minimise or eliminate risk?
Person responsible for implementing Control Measures:

First NameLast Name
When will the control measure be put in place:

DayMonthYear
Date
MANAGER to confirm that the above control measure has been implemented on the below date OR incident is CLOSED:

DayMonthYear
Date
Should be Empty:

MEDICATION INCIDENT REPORT

MANAGER USE ONLY