Medication Error or Near Miss Report Form
This form is to be read in conjunction with Medication Guidelines. This should be completed in conjunction with internal incident reporting procedures.
|Date Incident Reported | |
|Date/ Time Incident Occurred | |
|Incident Location | |
|Service User Details | |
|Service User Address | |
|Care Worker Name | |
|Care Worker Team | |
| |
|Indicate at which stage of the process the incident occurred |
|Prescribing |Ordering |Pharmacy Dispensing |
|Receipt |Administration |Recording |
|Other: | |
| |
|Medication Name & Description |
|Regular |Yes/No |Temporary |Yes/No |
| |
| |
|Details of Incident |
| |
| |
| |
|What do you think went wrong and why? |
| |
| |
| |
|Action Taken (e.g. contact GP) |
| |
| |
| |
|Outcome of Action (e.g. follow advice of GP) |
| |
| |
|Action taken as a result of error (e.g. further training, clarification of procedure) |
| |
| |
| |
| |
|Overall Outcome (e.g. Health of service User) |
| |
| |
| |
|What have you learnt, and what will be done differently as a result of this incident? |
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|Follow up action taken as a result of the incident? |
| |
| |
|Outcome of further training? (if applicable) (e.g. outcome of the further training, when it occurred, etc) |
| |
| |
| |
|Outcome of the QA? (e.g. discussion with the Care Worker, when this happened) |
| |
| |
| |
|Has Care Worker been provided with a copy of this document? Yes/No |
| |
|Care Worker signature (if required) |
|Recording Process Completed By: | |Date: | |
| Informed Manager □ Service User Home Updated □ Recorded on Medication Record □ |
| Internal Incident Report Complete □ Date on Agenda for Team Meeting : |
|Manager Signature | |Date: | |
Please email completed form to commcarefileaudit@.uk
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