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Medication Error Reporting Form : AIIMS Bhubaneswar
Event Details
Date of the Event
Time of the Event
(h:m:am/pm)
Location of the Event
- None -
Ward
OPD
Pharmacy
Others
Type of the Error
Prescribing
Administration
Dispensing
Other
Patient Details
First Name
Surname
CR Number
*
15-digit
Age (Year)
Age (Month)
Gender
- None -
Male
Female
Other
Description of the Event
Description of the Event : How did the event occur and how was it detected ?
Details of Medicines Involved in the Event
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
- None -
Once Daily
Twice Daily
Thrice Daily
Others
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
- None -
Once Daily
Twice Daily
Others
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
- None -
Once Daily
Twice Daily
Thrice Daily
Others
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
- None -
Once Daily
Twice Daily
Thrice Daily
Others
Sl. No.
Dosage Form
Generic Name
Strength
Frequency
- None -
Once Daily
Twice Daily
Thrice Daily
Others
Reachability of the Event and the Outcome
Did the Error Reach the Patient ?
- None -
Yes
No
Outcome of the Event
- None -
No Error
Error but not Harmful to the Patient
Error and Harmful to the Patient
Error and Death of the Patient
Specific
- None -
A. Events have potential to cause error
- None -
B. Error did not reach patient
C. Error reached patient, no harm
D. Error reached patient, no harm, need monitoring
- None -
E. Temporary harm requiring treatment
F. Temporary harm requiring hospitalization
G. Permanent harm
H. Near-death harm
- None -
I. Death
Possible Causes and Contributing Factors
Causes and Factors
Lack of Knowledge and Experience
Illegible Prescription
Look alike / Sound alike Medication
Wrong Labelling and Instruction
Use of Abbereviation
Unavailable Patient Information
Peak Hour and Overload
Miscommunication
Failure to adhere to Work Procedure
Others
Other Remarks
Details of Reporter (Optional)
First Name
Middle Name
Surname
Designation
Mobile Number (10-digit)
E-mail Address
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