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.
New York Medication Data Form — Medication Error and Near Miss Classification is a comprehensive system used to collect and classify medication errors and near misses that occur within healthcare facilities in the state of New York. This form aims to promote patient safety by identifying and analyzing patterns, causes, and contributing factors of medication errors and near misses. The Medication Data Form consists of different sections that capture specific details about the medication error or near miss event. These sections include: 1. Patient and Facility Information: This section captures basic demographic information about the patient and details about the healthcare facility where the event occurred. It includes the patient's name, age, gender, and relevant medical history along with the facility name, location, and type. 2. Medication Details: Here, the form collects information about the medication involved in the error or near miss event. This includes the medication name, strength, dosage form, route of administration, and any additional pertinent details about the medication. 3. Event Description: In this section, the form prompts the healthcare provider to provide a detailed description of the medication error or near miss event. This may include information about what happened, the sequence of events, any deviations from standard protocols, and any contributing factors that led to the error or near miss. 4. Classification and Causative Factors: The form allows for the classification of the medication error or near miss event based on predetermined categories such as wrong medication, wrong dose, wrong route, etc. It also provides a space to identify causative factors such as communication breakdown, lack of double-checking, or inadequate training. 5. Outcome and Potential Harm: Here, the form gathers information about the outcome of the medication error or near miss event. This includes details regarding any harm caused to the patient, ranging from no harm to severe harm or even death. Additionally, the form prompts healthcare providers to identify any preventative measures taken to avoid harm. 6. Reporting and Follow-up: The Medication Data Form requires information about the healthcare staff involved in the incident and the reporting processes followed within the facility. It also provides a space for any follow-up actions or interventions taken to address the error or near miss and prevent future occurrences. By using the New York Medication Data Form — Medication Error and Near Miss Classification, healthcare facilities can gain valuable insights into medication errors and near misses within their organization. These data can help identify areas for improvement, develop targeted interventions, and enhance patient safety protocols.
