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Medication

Occurrence

Information

Report/PI

Send

completed

form

Risk

Management

This

document

part

quality

improvement

process

CONFIDENTIAL:

Not

PHOTOCOPY

Not

File

Patient

Record

All

Sections

Must

Completed

ADDRESSOGRAPH

Patiant

age:

Definition

occurrence:

Any

preventable

event

thatmay

cause

lead

inappropriate

mecicaton use

patient

harm

while

the

medication

the

control

the

health

care

professional,

patent,

consumer.

Such

events

may

professional

practice,

health

care products,

procedures,

and

systems,

including

prescribing,

order

communication,

product

labeling,

packaging,

and

nomendiature;

compounding;

dispensing;

distribution;

administration;

education;

monitoring;

and

use.

Section

Report

filed

(please

print):

Location

event

Floor/LUnit:

Error

discovered:

Within

same

shift

(Within

hours

Staff

involved

initial

error:

Staff

Facility

Date

event:

Title:

Time

event

(24

hour):

Inpatient

Greater

than

hours

Date/Time:

Outpatient

Pharmacist

CINP

House

staff

Attending

Name:

Other

staff

also

involved

(i.6.,

perpetuated

the

error):

Staff

FacilityRN

Pharmacist

Health

care

provider

Staff

that

discovered

error:

Staff

FacilityRN

Pharmacist

Health

care

provider

notified?

[No

Yee

Date:

Health

care

provider

Time:

Attending:

Section

Medication

type:

Medication(s)

invalved:

Incident

documented

medical record?

[|Yes

Patientfamily

aware

incident?

Yes

Nor-lV¥

(lfyes,

please

comment

below)

TYPE

ERROR

BREAKDOWN

POINT

BREAKDOWN

POINT

(See

reverse

jor

definitions)

process

did the

inital

process

did

the

initial

error

oecur?,

Proc

pro

error

occur?)

(continued

from

the

column)

Prescribing

Preeeribing

Administration

Omission—Total

circle: circle:

Schedule:

illegible

handwriting

med

given,

but

not

charted

Monitoring

error

wrong

chart/onder

sheet

med

charted,

but

not

given

Wrong

patient

incorrect

held

med

given

Wrong

time

incomplete

order

incomect

medication

taken

from

floor

stock/Pyxis

and

Wrong

route

‘other,

please

describe

below

Wrong

dose/quantity/extra

Order

processing

USI

eee

Sane

dose

circle:

eae

dose

ordered

carbon

not

pulled/pulled

late

ettin

dose

given

order

not

transcribed

—pump

malfunction

Medication

DiC'd,

given

transcribed

incorrectly

—pump

turned

off

extra

doses:

athies

Please

describe

below

Other,

please

describe

below

Wrong

dug

sey

ERROR

SEVERITY/OUTCOME

eee

incorrectly

ontered

into

Category

Circumstances

events

that

have

the

amet

fanaa

capacily

cause

error

eee

Category

Error

occurred;

medication

not

given

Medication

not

ordered

entered

all

‘ a

Category

Medication

given

but

did not

cause

patient

harm

med

given

wrong

strength

sent

gene

Penrose

Category

Resulted

the

need

for

increased

patient

(]

Wrong

drug

preparation

(Wrong

rate

administration

Given

patient with

known

Investigational

protocol

not

followed

C1)

Other

label

incorrect/unclear

delay

delivery

medication

other,

please

describe

below

feontinued

column)

monitoring

but

harm

Category

Resulted

the

need

for

treatment

intervention

and

caused

temporary

patient

harm

Category

Resulted

initial

prolonged

hospitalization

and caused

temporary

patient

harm

Category

Resulted

permanent

patient

harm

Category

Resulted

a near-death event

(e.g.,

anaphylaxis,

cardiac

arrest)

Category

Resulted

patient

death

COMMENTS,/DESCRIBE

EVENT

(include

any

intervention‘treatment

given

and

outcome):

Section

ANALYSIS/RECOMMENDATIONS/ACTION

PLAN

/ifanager

compe):

Possible

causes:

abbreviation

calculation

eror

communication

confusing/intimidating/lacking

computer

order entry

decimal

point/leading

zero

missingftrailing

zero

equipment

design

facsimile

order

handwriting

ileable

inexperienced

staff

staffina

level

labelina

(GUM)

confusinalincomolete/inaccurate

labeling

(manufacturer\

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