York County Board of Disabilities and Special Needs

YorkCounty Board of Disabilities and Special Needs

Medication Error/Event Report

First: / Middle: / Last: / Reisidence:
Date of Birth:
/ /
MM DD YY / Sex:
□ Male
□ Female / Date of Med Error: / Time of Med Error: / Date Error Found:
Residence of Consumer:
□ CRCF □ CTH II □ SLP–I □ SLP – II
□ Lives at home with family/guardian / Location of Med Error/Event:
□ CRCF □ CTH II □ SLP I □ SLP 2
□ Day Program
□ At home with family □ Other (specify): ______
Name of Medication Involved / Dose / Frequency
What type of Med Error/Event Occurred: (Mark all that apply)
□ Wrong person given the medication □ Transcription Error □ “Near Miss” for a Med-Error
□ Wrong medication given □ Medication not signed off on properly □ Person refused medication
□ Wrong dosage given □Medication found Number of attempt_____
□ Wrong route of administration Method______
□ Wrong time Attach copy of UBR
□ Medication not given □ Unsafe circumstances
□ Medication given without order
What was the result of the Med Error/Event:
(At the time the Report was completed)
□ No Error (Near Miss or Red Flag Event)
□ Error, No Reaction
□ Error, Reaction, No Medical Rx Required
□ Error, Reaction, Medical Rx Required**
□ Error, Reaction, Death** / Prescriber Notified: Yes □ No □
When: ______
By Whom: ______
If no, explain:
Staff Suspected of Making the Error:
Description of Med Error/Event:
Name of Prescriber: / Name of Pharmacy: / Signature of Person Making Out Report/Date:
Forward original to House Manager to Coordinator to Lead Nurse Coordinator. Do not send copies.
Signature of House Manager: Date: / Signature of Coordinator: Date:
Signature of Lead Community Nurse Coordinator: Date: / Signature of Program Director: Date:
**Requires the completion of Critical Incident Report as per 100-09-PD. / Family Member Notified: (CRCF) Date: