Exhibit IV - Medication Error Report.pdf
PDF 65 KB Posted
- Attached to
- Master Agreement AZ|CTR071666
- Contract number
- CTR071666
- Issued by
- Arizona
About this file
The document is a Congregate Care Medication Error Report form issued by the Arizona Department of Child Safety. It is designed to document and track medication errors in child care settings, with a focus on confidential reporting and intervention. The form is specifically labeled as Exhibit IV (05/24) and provides a structured template for recording details of medication administration incidents.
The form allows for comprehensive documentation of medication errors, including type of error (such as wrong medication, wrong dose, missed doses, or medication not given at the right time), incident details, immediate actions taken, and follow-up prevention measures. It includes sections for identifying the provider/facility, location of occurrence, staff involved, consumer information, and notification requirements. The form provides checkboxes for various types of medication errors and spaces for describing the incident, immediate interventions, and agency follow-up, emphasizing a systematic approach to tracking and preventing medication mistakes 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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File details come from the government source that posted it. Updated .