Exhibit IV - Medication Error Report.pdf
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- Attached to
- Master Agreement AZ|CTR071438
- Contract number
- CTR071438
- Issued by
- Arizona
About this file
The document is a Congregate Care Medication Error Report form from the Arizona Department of Child Safety. It is a standardized two-page confidential form designed to document and track medication errors in child care settings. The form is marked as Exhibit IV with a version date of 05/24 and includes provisions for reporting various types of medication administration mistakes.
The form provides comprehensive fields for documenting medication error incidents, including details such as the date of the error, location of occurrence, staff members involved, type of medication error (e.g., wrong medication given, incorrect dose, missed doses), and spaces for describing the incident, immediate actions taken, and follow-up prevention strategies. The form also includes notification checkboxes for DCSS (Department of Child Safety Services), pharmacy, and physician, with an option to complete an Unusual Incident Report. The primary purpose is to create a structured method for tracking, reporting, and preventing medication administration errors in congregate care settings for children.
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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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