Exhibit IV - Medication Error Report.pdf
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- Attached to
- Master Agreement AZ|CTR071410
- Contract number
- CTR071410
- Issued by
- Arizona
About this file
This document is a Congregate Care Medication Error Report form created by the Arizona Department of Child Safety. The standardized two-page form is designed to document and track medication errors in congregate care settings, with a focus on confidentiality and detailed incident reporting. The form is labeled as Exhibit IV with a date of 05/24 and provides comprehensive sections for recording incident details, types of medication errors, description of the incident, immediate actions taken, and follow-up prevention measures.
The form includes multiple checkboxes for various types of medication errors, such as medication given to the wrong person, wrong dose, missed doses, medication not given at the right time, and other potential administrative or procedural mistakes. It requires detailed documentation including the date of the medication error, location of occurrence, staff member involved, consumer information, and notification requirements. The form allows for reporting to multiple entities including DCSS, pharmacy, and physician, and includes a section for an unusual incident report. The purpose appears to be creating a systematic method for tracking, reporting, and preventing medication errors in child safety 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 .