MEDICATION OCCURRENCE REPORT
Name of Individual: ______Region: ______DOB:______
Date(s) of Occurrence:______Time of Occurrence:______ AM PM
Certification Address: ______Name of Provider Agency: ______
Type of Service: He-M 1001 507 518 521 524 525 Other______
MEDICATION ERROR DOCUMENTATION ERROR OTHER CONCERNS
Wrong Med Med log error Missing med
Wrong Time Controlled Drug Count not done Unauthorized person
Wrong Dose Controlled Drug Count incorrect administered med
Wrong Person Other______Other______
Wrong Route
Omission
Name of Medication(s) Involved / Dose: / Frequency: / Route: / Purpose of Medication:Describe what happened (including any impact to individual):
______
______
______
Name, Date & Time Nurse Trainer was notified: ______By Whom: ______
Instructions received from Nurse Trainer: ______
______
______
Action(s) Recommended by Medical Professional & Taken by Authorized Provider (person authorized to administer meds)______
Who was notified (Include name, date/time and method of contact) (Guardian notification, if applicable):Name / Relationshipto individual / Date / Time / Method of contact
Service Coordinator / am pm
Program Supervisor / am pm
Guardian(s) / am pm
Prescribing Practitioner / am pm
Report written by: ______Date: ______
MEDICATION OCCURRENCE REPORT- Page 2
Name of Individual: ______Date(s) of Occurrence: ______
TO BE COMPLETED BY THE PERSON RESPONSIBLE FOR THE OCCURRENCE:
Person responsible for Medication Occurrence:______
Describe How and Why the Occurrence Happened: ______
Suggestions to prevent future occurrence: ______
______
Signature of Person Responsible: ______Date Completed: ______
NURSE TRAINER REVIEW: to be completed by Nurse Trainer
Type of Occurrence: ______
Cause of Occurrence: ______
______
Immediate Actions taken in regard to this situation/ Authorized Provider (e.g. corrective action): ______
______
Systemic Recommendations to prevent future occurrence(s): ______
______
Signature of Nurse Trainer: ______Date completed: ______
MANAGEMENT REVIEW: to be completed by Program Director/ Designee
Review of Authorized Provider and Nurse Trainer Response & Include any Additional Follow-up:
______
______
Signature of Program Director/ Designee: ______Date Completed: ______
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Revised 6/7/17