Medication Error Report Form

Medication Error Report Form
Complete the following form when a medication error is discovered. This information needs to be shared with your The Right Home Care Team as soon as possible following the discovery.
Monthly AuditDaily CheckOther
What was the primary reason for the error

Recording errorMissed signatureWrong personWrong dose/amountWrong medicineOmission of doseWrong time
If recording error

Incorrect handwritten errorhandwritten not counterError with stock carry forwardOther
If other, please give details
What was the secondary reason for the error (if appropriate)

Recording errorMissed signatureWrong personWrong dose/amountWrong medicineOmission of doseWrong time
Who made the error

PrescriberPharmacyDN/ANPOther
Please give details for the person/pharmacy:
Time of administration

MorningLunchTeaEveningOther
If other, please give details
Which medicine does this relate to

Topical/creamCapsule/tab/liquidControlled drugsInhaler/sprayRescue medicationEye dropsInjection

Immediate action taken

Contacted GP/ANPPhoned 111Phoned 999Monitoring of person healthRecording error onlyInformed personInformed familyAdmitted to hospitalContacted pharmacistInformed manager
Give details of the above action taken:
Should be Empty: