This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.
Illinois Medication Data Form - Medication Error and Near Miss Classification
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Date(s) of error(s) (month, day, year) Time(s) of error(s) Describe the medication error. (Include name of medication, dose, and route; attach an extra sheet of paper if necessary.) CAUSE(S) OF MEDICATION ERROR(S) (Check all that apply.)
Adopt a reporting system. The only way to reduce medication errors is to develop a reporting system and then make changes to prevent similar errors from reoccurring. Even a near miss should be reported. The staff should be encouraged to report without any repercussions.
The ASHP classifies errors as prescribing error, dispensing error, omission error, wrong time error, unauthorized drug error, improper dose error, wrong dosage-form error, wrong drug-preparation error, wrong administration-technique error, deteriorated drug error, monitoring error, compliance error, and other ...
When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). ... Initial and date the entry. State the reason for the error (i.e. in the margin or above the note if room). Document the correct information.
Reporting Medication Errors Examples include the Institute of Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA). These organizations collectively review error submissions. Case reports are published to educate health care professionals regarding errors and near errors.
Write a note in the medical record documenting what happened, the impact on the patient, treatment provided, and results. You can include who was told about it, what they were told, and when. The clinical record is the wrong place to guess what happened or to blame others.
Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, ?mistaken entry, wrong medication name written.? Follow facility policy when adding late information.
The Institute for Safe Medication Practices further defines a near miss as ?any event or situation that didn't produce patient injury, but only because of chance.?2 For reporting purposes, a near miss is considered an error, as is a medication error that doesn't result in patient harm.