Medication incident and discrepancy report form 2025

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Since 2005, pharmacy contractors have been required to record patient safety incidents in an incident log and report these to the National Reporting and Learning Service (NRLS).
A mechanical error is a mistake in dispensing or preparing a prescription, such as administering an incorrect drug or dose, giving improper directions, or dispensing the incorrect dose, quantity, or strength.
Include the type of error (e.g., wrong dosage, wrong medication), the exact medication involved, the time it occurred, and any immediate actions taken. Follow the services protocol for reporting medication errors. This typically involves completing an incident report form, some of which may be electronic.
Example: converting form codeine to morphine in pregnancy resulting in an unintended dose increase. Prescribing medication at a frequency below or higher than that recommended by the BNF/BNFC or SPC so where there is a low potential to cause harm. Example: Mild hydrocortisone cream in an adult.
An incident report should be completed immediately after an incident has occurred and appropriate corrective action followed. Incident reports are integral to a functional healthcare system that is committed to ongoing improvement and transparency.
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Changing a medication dose, removal or addition of a medication during hospital admission without a justification are common examples on discrepancies (Mueller et al., 2012, Quelennec et al., 2013). In addition, medication discrepancies have been identified as either intentional or unintentional (Kwan et al., 2013).
Tolerance is a decrease in response to a drug that is used repeatedly. Resistance is development of the ability to withstand the previously destructive effect of a drug by microorganisms or tumor cells. Examples of drugs that result in tolerance include alcohol and opioids.

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