ADVERSE EVENT OUTCOME REPORT - NAHC
ADVERSE EVENT OUTCOME REPORT Report Period______________________
EMERGENT CARE FOR IMPROPER MEDICATION ADMINISTRATION, MEDICATION SIDE EFFECTS
Definition: The patient received emergent care after SOC/ROC, and the emergent care reason was "improper medication administration, medication side effects, toxicity, anaphylaxis."
OASIS M0 triggers: M0830, M0840 (Transfer/Discharge)
Pt. Name __________________________________ SOC date ________ D/C date________ Age ___________
Review Date ___________________ Reviewer_____________________________________________________
|QUESTIONS |YES |NO |IE |COMMENTS |
|Was the patient treated emergently for improper medication administration, medication side effects,| | | | |
|toxicity, anaphylaxis? | | | | |
| If no, was there an error in the OASIS documentation? | | | | |
| If yes, which one? | | | | |
|If the documentation does not support the definition of the adverse outcome, stop the audit at this point. |
| If Improper medication administration explain: | | | | |
| Was pt independent in med administration? | | | | |
| Was the patient taught safe med set-up, if needed? | | | | |
| Who administered the med improperly? | | | | |
| If for med side effect or toxicity, explain: | | | | |
| Was the pt/cg taught the side effects of the medication? | | | | |
| Did the patient demonstrate understanding of teaching? | | | | |
| Did the pt/cg report this side effect to the clinician? | | | | |
| Was physician notified appropriately? | | | | |
|IE = Insufficient evidence documented to make decision/not documented |
ADVERSE EVENT OUTCOME REPORT-Improper Medication Administration, Medication Side Effects
|QUESTION |YES |NO |IE |COMMENTS |
|If for anaphylaxis, explain: | | | | |
| Was the patient allergic to the medication? | | | | |
| Was this a first time dose? | | | | |
| Was there an anaphylaxis kit in the home? | | | | |
| Was the physician notified immediately? | | | | |
| Was 911 called? | | | | |
|Caregiver - Support Systems | | | | |
| Did the patient require the assistance of a caregiver? | | | | |
| Was the caregiver, if required, constantly available? | | | | |
| Was the caregiver present? | | | | |
| If present, who was it? (e.g. family, friend, aide, etc.) | | | | |
|Patient Status - Mental | | | | |
| Was the patient cognitively impaired or having periods of | | | | |
|confusion? | | | | |
| Did the patient had visual impairments? | | | | |
| | | | | |
|Conclusions |
|Based on the documentation, could this adverse outcome have been prevented? YES NO UNSURE |
|If yes, what may have been done to prevent the adverse outcome: |
| |
|If no, explain: |
| |
|If uncertain, explain: |
| |
| |
| |
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