Exhibit IV - Medication Error Report.pdf
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- Attached to
- Master Agreement AZ|CTR071425
- Contract number
- CTR071425
- Issued by
- Arizona
About this file
This document is a Congregate Care Medication Error Report form from the Arizona Department of Child Safety. The two-page form is designed to document and track medication errors within child care facilities, with an emphasis on confidentiality and detailed incident reporting. The form is marked as Exhibit IV and dated 05/24, and provides a structured template for recording medication administration mistakes, potential notifications, and follow-up actions.
The form allows for comprehensive documentation of medication errors, including specific checkboxes for error types such as medication given to the wrong person, wrong dose, missed doses, incorrect administration timing, and other potential medication management issues. The report includes sections for incident information, description of the incident, immediate actions and interventions, and follow-up prevention steps taken by the agency. Notification options include DCSS, Pharmacy, and Physician, with a provision for completing an Unusual Incident Report. The form is designed to ensure thorough tracking and potential remediation of medication administration errors in congregate care settings.
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Text version
CONGREGATE CARE
MEDICATION ERROR REPORT
ARIZONA DEPARTMENT OF CHILD SAFETY
This document is subject to confidentiality requirements and should be handled accordingly.
Exhibit IV (05/24)
PID No. Dose Dose DoseDOB Time Given Time Given Time Given
Report Date (.mm/dd/yy)
Date of Med. Error (mm/dd/yy)
Please document all information clearly and use a separate form for each occurrence.
Description of incident
Immediate Action and Intervention
Provider/Facility
Location of Occurrence
City
Phone No.
State Zip
Time
Site Address Incident Information
Type of Medication Error Involved
Notifications
Individual completing this report
Name of Staff member involved Consumer Name of Medication Name of Medication Name of Medication
Title
Title
Signature
Medication given to the wrong person Medication refill not ordered timely (missed doses) Wrong medication given
Family error
DCSS Pharmacy Physician
Newly prescribed order not initiated within 24 hours Medication administration record not accurately documented Medication not given at the right time
Other
Wrong dose of medication given Shift to Shift count on controlled medication not accurate Medication not given
Client refused medication
Unusual Incident Report Completed
CONGREGATE CARE
MEDICATION ERROR REPORT
ARIZONA DEPARTMENT OF CHILD SAFETY
This document is subject to confidentiality requirements and should be handled accordingly.
Exhibit IV (05/24)
Follow up and prevention taken by Agency
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