Exhibit IV - Medication Error Report.pdf
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- Attached to
- Master Agreement AZ|CTR071417
- Contract number
- CTR071417
- Issued by
- Arizona
About this file
This document is a Congregate Care Medication Error Report form issued by the Arizona Department of Child Safety. The form is designed to document and track medication errors in congregate care settings, with specific emphasis on confidentiality and thorough incident reporting. The form is labeled as Exhibit IV with a date of 05/24 and provides a structured template for recording details of medication administration mistakes.
The form includes comprehensive sections for capturing incident information such as the date and time of the medication error, location of occurrence, staff member involved, and the specific type of medication error. Potential error types range from medication given to the wrong person, wrong dose, missed doses, to documentation inaccuracies. The form also includes fields for describing the incident, immediate actions taken, interventions performed, and notifications to relevant parties like DCSS, pharmacy, or physician. A section for follow-up and prevention by the agency is also provided, allowing for a systematic approach to addressing and preventing future medication errors.
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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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