Exhibit IV - Medication Error Report.pdf
PDF 65 KB Posted
- Attached to
- Master Agreement AZ|CTR071450
- Contract number
- CTR071450
- Issued by
- Arizona
About this file
This document is a Congregate Care Medication Error Report from the Arizona Department of Child Safety, designed to document and track medication errors in child care settings. The form is marked as Exhibit IV (05/24) and is subject to confidentiality requirements, indicating it is an official internal reporting instrument for tracking and addressing medication administration incidents.
The report form provides a comprehensive template for documenting medication errors, including detailed sections for incident information, types of medication errors, description of the incident, immediate actions and interventions, and follow-up prevention steps. The form allows for recording specific details such as the date and time of the error, location, staff members involved, consumer information, medication names, dosages, and notification requirements. Potential medication error types include wrong medication given, incorrect dosage, missed doses, administration record inaccuracies, and medication not given at the right time or to the right person. The form also includes checkboxes for notifications to DCSS, pharmacy, physician, and an option to complete an unusual incident report.
View the file
Other files
Show all 41
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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
| Text Field 16: |
| Text Field 18: |
| Text Field 20: |
| Text Field 22: |
| Text Field 17: |
| Text Field 19: |
| Text Field 21: |
| Text Field 23: |
| Text Field 36: |
| Text Field 0: |
| Text Field 7: |
| Text Field 37: |
| Text Field 38: |
| Text Field 1: |
| Text Field 9: |
| Text Field 4: |
| Text Field 2: |
| Text Field 5: |
| Text Field 6: |
| Text Field 8: |
| Text Field 3: |
| Text Field 44: |
| Text Field 10: |
| Text Field 11: |
| Text Field 12: |
| Text Field 13: |
| Text Field 14: |
| Text Field 45: |
| Text Field 15: |
| Text Field 46: |
| Check Box 24: Off |
| Check Box 32: Off |
| Check Box 28: Off |
| Check Box 27: Off |
| Check Box 35: Off |
| Check Box 31: Off |
| Check Box 39: Off |
| Check Box 40: Off |
| Check Box 41: Off |
| Check Box 26: Off |
| Check Box 34: Off |
| Check Box 30: Off |
| Check Box 25: Off |
| Check Box 33: Off |
| Check Box 29: Off |
| Check Box 42: Off |
| Text Field 43: |
File details come from the government source that posted it. Updated .