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Medication error reporting form template 2025

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The document outlines the Medication Error Reporting Form from the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), designed as a blame-free tool for healthcare professionals to report medication errors. It defines medication errors, provides examples, and emphasizes the importance of reporting such incidents to improve patient safety. The form collects details about the event, patient information, type of error, possible causes, outcomes, and interventions taken. It assures confidentiality for reporters and encourages immediate reporting without strict timelines.

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Click ‘Get Form’ to open the medication error reporting form template in our editor.
Begin by filling in the 'Date of event', 'Time of event', and 'Location of event' sections. Choose from options like Ward, OPD, Pharmacy, or Others.
Next, provide patient details including 'Age', 'Gender', and 'Diagnosis'. This information is crucial for understanding the context of the error.
In the 'Type of error' section, select the appropriate option: Dispensing, Prescribing, or Administration.
Describe the event in detail in the provided space. Explain how it occurred and how it was detected.
List details of medicines involved in the event including Generic Name, Dosage, Strength, and Frequency.
Indicate whether the error reached the patient by selecting Yes or No.
Select the outcome of the event from options such as No error, Error with harm, or Near death event.
Identify possible causes and contributing factors by checking relevant boxes.
Optionally fill out your details in the 'Details of reporter' section before submitting your report.

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What is an example of a medication error incident?

An incorrect dosage form occurs when a patient receives a dosage different than prescribed, such as immediate-release instead of extended-release. Patients incorrectly taking a medication is considered a medication error. Patient education is the only way to prevent this type of error.

How do I report a medication error?

If you need information or if you have questions or comments about a medical product, please call the FDAs toll-free information line, 1-888-INFO-FDA (1-888-463-6332) Press 2 to report into MedWatch or for instructions.

How do I write a report on a medication error?

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.

What information must be included in an incident report regarding a medication error?

A medication error report should include details of the error, patient information, medication details, personnel involved, error description, impact on the patient, corrective actions taken, and recommendations for preventing future errors.

What are the 5 steps for medication error?

One of the recommendations to reduce medication errors and harm is to use the five rights: the right patient, the right drug, the right dose, the right route, and the right time.

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Key Facts about the JIPMER Medication Error Reporting Form

Blame-Free Reporting

Mandatory Fields

Comprehensive Error Types

Confidentiality Assured

Immediate Reporting Encouraged

Wide Accessibility

Who Can Report?

Blame-Free Reporting

The form is designed as a blame-free reporting tool, encouraging healthcare professionals to report medication errors without fear of repercussions.

Mandatory Fields

All fields in the form must be filled out except for the details of the reporter, which are optional.

Comprehensive Error Types

The form allows for reporting various types of medication errors including dispensing, prescribing, and administration errors.

Confidentiality Assured

There are no confidentiality issues as identifiers like patient names or hospital numbers do not need to be reported.

Immediate Reporting Encouraged

Healthcare professionals are encouraged to report medication errors immediately upon discovery, although there is no strict timeline.

Wide Accessibility

The medication error reporting forms are freely available in all wards and OPDs and can also be downloaded from the JIPMER website.

Who Can Report?

Any healthcare professional, including doctors, nurses, pharmacists, and allied health professionals, can report medication errors using this form.

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How to write an incident report on a patient?

Incident reporting needs may vary by organization, but this basic information is generally required: Patient name, date of birth, and hospital ID number. Names of any other affected individuals (e.g., staff or visitors) Date, time, and location of the incident. Name and address of the facility where the event occurred.

How do you document a medical error?

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.

How to record a medication error?

The record should include details of the medication error, when the error occurred, how it was discovered, how and why it occurred. The corrective actions taken to manage the error and the patients care should be recorded.

Medication error reporting form template 2025

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How to use or fill out medication error reporting form template with DocHub

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Got questions?

What is an example of a medication error incident?

How do I report a medication error?

How do I write a report on a medication error?

What information must be included in an incident report regarding a medication error?

What are the 5 steps for medication error?

Key Facts about the JIPMER Medication Error Reporting Form

Blame-Free Reporting

Mandatory Fields

Comprehensive Error Types

Confidentiality Assured

Immediate Reporting Encouraged

Wide Accessibility

Who Can Report?

Blame-Free Reporting

Mandatory Fields

Comprehensive Error Types

Confidentiality Assured

Immediate Reporting Encouraged

Wide Accessibility

Who Can Report?

Complete this form in 5 minutes or less

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How to write an incident report on a patient?

How do you document a medical error?

How to record a medication error?

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