1. Medication Safety Is Everyone’s Responsibility
Quality related event reporting form - CONFIDENTIAL
Report Date: ______________
Reporting Pharmacist Info
Name: ___________________________________phone no: _____________________
Title: _________________________Signature: ________________________________
Data reporting
Date of Error: ____________________________ Date discovered: ________________
Person discovering the error: _______________________________________________
Pharmacist involved in error: ________________________phone no: ______________
Others involved in error (include title): ________________________________________
______________________________________________________________________
Pharmacy information
Pharmacy name and Address: _____________________________________________
City, State, Zip: _________________________________________________________
Phone no: ___________________________ Fax no: ___________________________
Patient info
Name: ______________________________________________Dob: ______________
Address: _______________________________________________________________
City, State, Zip: _________________________________________________________
Phone no: __________________________ Allergy_____________________________
Original Prescription Info
Drug name and dose: ____________________________________________________
Sig: _____________________________________Quantity: ______Date: ___________
Prescriber name: ________________________________________________________
Address: _______________________________________________________________
City, State, Zip: _____________________________Phone: ______________________
Incorrect Prescription Info: _______________________________________________
______________________________________________________________________
How the Rx was received
Hard copy Electronic Voicemail Phone
Type of Error
Wrong patient Wrong medication Wrong Strength
Wrong dosage form Wrong amount Medication interactions
Medication contraindicated Medication expired Labeled incorrectly
Other (please describe): _________________________________________________
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2. Medication Safety Is Everyone’s Responsibility
Was patient counseled? Yes No Was patient offered counseling: Yes No
Reason for not offering counseling: __________________________________________
______________________________________________________________________
Please provide a complete account of this error: ____________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Describe the corrective action taken: ______________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Notification:
Did error reach to the patient? No Yes
If yes, Patient notified: No Yes Date: ______________
Prescriber notified: No Yes Date: ______________
Supervisor notified: No Yes Date: ______________
Does supervisor need to follow up with the patient: Yes No
Was patient harmed? No Yes
If yes, did patient see any doctor because of error: No Yes
If yes, MD info: ___________________________________________________
Where in the workflow the error occurred
Entry process Filling process
Verifying process Delivery
Compounding Counseling
Other (please describe)
Cause/Contributing factors: ______________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Suggestion to avoid similar occurrence: ___________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
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3. Medication Safety Is Everyone’s Responsibility
Return to: Perry Modi or fax to: 7732751478
5244 N. Sheridan Rd, Chicago, IL,60640
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