Medication Error Report - APD



THIS DOCUMENT IS SUBJECT TO CONFIDENTIALITY REQUIREMENTS AND SHOULD BE HANDLED ACCORDINGLYClient: FORMTEXT ????? Date of Birth (mm/dd/yy): FORMTEXT ?????Discovery Type: Provider reported FORMCHECKBOX APD discovery FORMCHECKBOX QIO discovery FORMCHECKBOX Other FORMCHECKBOX (describe): FORMTEXT ?????Please Print All Information Clearly and Use One Form For Each Occurrence Report Date (mm/dd/yy): FORMTEXT ????? Time FORMTEXT ?????Agency/Provider Name: FORMTEXT ????? FORMCHECKBOX Group Home FORMCHECKBOX Family Home FORMCHECKBOX Supported Living FORMCHECKBOX Independent Living FORMCHECKBOX Day Program FORMCHECKBOX Other FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT FLZip: FORMTEXT ?????Individual Completing This Report: FORMTEXT ????? Title: FORMTEXT ?????Signature: FORMTEXT ?????Name of all Staff Members Involved (use additional pages if needed): Name: FORMTEXT ????? Title: FORMTEXT ?????Medication Validated? Yes FORMCHECKBOX No FORMCHECKBOX Name: FORMTEXT ????? Title: FORMTEXT ????? Medication Validated? Yes FORMCHECKBOX No FORMCHECKBOX Name: FORMTEXT ????? Title: FORMTEXT ????? Medication Validated? Yes FORMCHECKBOX No FORMCHECKBOX Error Made by RN or LPN? Yes FORMCHECKBOX No FORMCHECKBOX IF Yes, Name of Nurse: FORMTEXT ?????ALL MEDICATIONS INVOLVED IN ERROR MUST BE LISTED. USE ADDITIONAL PAGES IF NEEDED.Describe all errors involving times in description of incident.DATE OF ERROR: FORMTEXT ?????Name of Medication: FORMTEXT ?????Dose: FORMTEXT ?????Time Given: FORMTEXT ?????Total doses involved: FORMTEXT ?????Name of Medication: FORMTEXT ?????Dose: FORMTEXT ?????Time Given: FORMTEXT ????? Total doses involved: FORMTEXT ?????Name of Medication: FORMTEXT ?????Dose: FORMTEXT ?????Time Given: FORMTEXT ????? Total doses involved: FORMTEXT ?????ARE ANY OF THE MEDICATIONS LISTED CONTROLLED SUBSTANCES: YES FORMCHECKBOX NO FORMCHECKBOX Type of Medication Error Involved: Please select the option that best fits the type of error. If you select “Other”, please explain FORMCHECKBOX Wrong Medication Given* FORMCHECKBOX Administration of medication for any symptom, illness, or reason For which it was not prescribed (wrong reason = wrong medication) FORMCHECKBOX Administration of medication for which there is no current prescription or MD order FORMCHECKBOX Wrong Dose of Medication Given* FORMCHECKBOX Administration of an incorrect dose of medication FORMCHECKBOX Administration of more than one dose of the same medication in a scheduled time period FORMCHECKBOX Medication Given to the Wrong Person* (Administration of medication prescribed for someone else) FORMCHECKBOX Medication Not Given at the Right Time* FORMCHECKBOX Wrong Route* FORMCHECKBOX Medication Administration Record Not Immediately and Accurately Documented FORMCHECKBOX Medication given by staff not validated per 65G-7.004 FORMCHECKBOX Shift to Shift Count on Controlled Medication Not Accurate FORMCHECKBOX Other error (except not given) FORMCHECKBOX Administration of expired or improperly labeled Medication FORMCHECKBOX Medication Not Given* (select reason not given below) FORMCHECKBOX Client refused medication FORMCHECKBOX Legal Rep. refused for client FORMCHECKBOX Failed to give FORMCHECKBOX Medication not available (select reason not available below) FORMCHECKBOX New order not initiated within 24 hours FORMCHECKBOX Refill not ordered timely FORMCHECKBOX Insurance Issue FORMCHECKBOX Pharmacy Issue FORMCHECKBOX Family Error (Explain) FORMCHECKBOX Other not given reason (Explain)* Error type starred above must be reported to healthcare practitioner Did medication error result in MD or ER Visit or Hospitalization? Yes FORMCHECKBOX No FORMCHECKBOX IF Yes, include explanation in description belowDescription of Incident and Immediate Action or Intervention (Include any medical care required): WHO WHAT WHEN WHY HOW FORMTEXT ?????If medical care required, please describe care and current status of individual FORMTEXT ?????Notification: FORMCHECKBOX Physician, PA, or APRN Name: FORMTEXT ????? (Must be notified for errors starred above) FORMCHECKBOX Family/Guardian FORMCHECKBOX Support Coordinator Name: FORMTEXT ????? (Must be notified) FORMCHECKBOX Abuse Registry FORMCHECKBOX Developmental Disabilities Office FORMCHECKBOX Other-List: FORMTEXT ?????___________________________________________________________________________________________________________This Section to be Completed by Supervisory Personnel (APD Provider) Follow-up/Corrective Action taken or Plans (to prevent future occurrence): Select from options below FORMCHECKBOX 65G-7 Medication Administration Re-training and validation required FORMCHECKBOX Verbal warning to staff by provider FORMCHECKBOX Focused -training by Provider on 65G-7 FORMCHECKBOX Written warning to staff by provider FORMCHECKBOX Technical assistance by MCM FORMCHECKBOX Counseling to staff by provider FORMCHECKBOX Provider policy written/trained FORMCHECKBOX Insurance issue FORMCHECKBOX Staff no longer allowed to give medications FORMCHECKBOX Physician issue FORMCHECKBOX Staff Terminated FORMCHECKBOX Other (Explain in WHO WHAT WHEN HOW section) FORMCHECKBOX Pharmacy issueWHO WHAT WHEN HOW of Corrective Action taken or Plans to prevent future occurrence FORMTEXT ?????Name of Supervisory Personnel: FORMTEXT ?????Title: FORMTEXT ?????Signature: FORMTEXT ?????Contact Phone Number: FORMTEXT ?????_________________________________________________________________This Section to be completed by Department (APD/MCM)Date Report was received by DD Office (mm/dd/yy): FORMTEXT ?????Total doses involved in all: FORMTEXT ?????Follow-up Recommended by DD Office: FORMCHECKBOX 65G-7 Medication Administration Re-training and validation required* FORMCHECKBOX Verbal warning to staff by provider FORMCHECKBOX Focused -training by Provider on 65G-7 * FORMCHECKBOX Written warning to staff by provider FORMCHECKBOX Technical assistance by MCM FORMCHECKBOX Counseling to staff by provider FORMCHECKBOX Provider policy written/trained FORMCHECKBOX Insurance issue FORMCHECKBOX Staff no longer able to give medications FORMCHECKBOX Physician issue FORMCHECKBOX Will accept provider’s follow-up/corrective action FORMCHECKBOX Other (Explain in notes section) FORMCHECKBOX Pharmacy issue*Please complete and submit documentation of training to the Area office MCM by FORMTEXT ?????. It is the recommendation of the APD MCM that the following person(s) take the above mentioned training: FORMTEXT ?????Date APD-recommended follow-up completed: FORMTEXT ????? Date provider-recommended follow-up completed: FORMTEXT ?????Notes: FORMTEXT ????? ................
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