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NURHANANI ABD HALIM
PHARMACY ASSISTANT PsSH
FLOW & CHART NEAR/MISSED
MEDICATION ERROR
Error detected
Fill in
near/missed
medication form
•Form can be taken in second row drawer
Keep filled form in
second row
drawer
•Form also can be filled at the end of the shift.
Data compiled by
PIC at the end of
the month and
submitted to HOS.
Near/Missed Medication Report
Form
Example:
Staff A
Staff B
Staff A
-
01 January 2020 12:30pm
Checker detected.
Change to Arcoxia 90mg
tab immediately.
Tab Arcoxia 120mg was
prescribed but wrong strength
medication prepared.
Staff B
01 January 2020
Wrong
Frequency
Wrong
Route
Expired
Drugs
Wrong
Formulation
Allergy
Medication Error Types
COMPILED MONTHLY REPORT
BIL DATE TIME
STAFF
INVOLVE
CASE DESCRIPTION
MRN
(OP/IP/DC)
PRESCRIBER TYPE OF ERROR* RCA
REPORT SUBMIT
DATE
eg 10/07/2020 1030H Staff A 12568 (OP) DR AZAM B
1 30/06/2020 1530H
HANANI
FARHANA
9560 (IP) DR AZAM D
IV Nexium given instead of IV
Panto. Detected by staff nurse.
2 D IV
3
4
5
6
7
*CODE TYPE OF ERROR
A ALLERGY
B WRONG FREQUENCY
C WRONG ROUTE
D WRONG FORMULATION
E EXPIRED DRUG
Medication Error Reporting

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Medication Error Reporting

  • 2. FLOW & CHART NEAR/MISSED MEDICATION ERROR Error detected Fill in near/missed medication form •Form can be taken in second row drawer Keep filled form in second row drawer •Form also can be filled at the end of the shift. Data compiled by PIC at the end of the month and submitted to HOS.
  • 3. Near/Missed Medication Report Form Example: Staff A Staff B Staff A - 01 January 2020 12:30pm Checker detected. Change to Arcoxia 90mg tab immediately. Tab Arcoxia 120mg was prescribed but wrong strength medication prepared. Staff B 01 January 2020
  • 5. COMPILED MONTHLY REPORT BIL DATE TIME STAFF INVOLVE CASE DESCRIPTION MRN (OP/IP/DC) PRESCRIBER TYPE OF ERROR* RCA REPORT SUBMIT DATE eg 10/07/2020 1030H Staff A 12568 (OP) DR AZAM B 1 30/06/2020 1530H HANANI FARHANA 9560 (IP) DR AZAM D IV Nexium given instead of IV Panto. Detected by staff nurse. 2 D IV 3 4 5 6 7 *CODE TYPE OF ERROR A ALLERGY B WRONG FREQUENCY C WRONG ROUTE D WRONG FORMULATION E EXPIRED DRUG