Exhibit IV - Medication Error Report.pdf
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- Attached to
- Master Agreement AZ|CTR071449
- Contract number
- CTR071449
- Issued by
- Arizona
About this file
This is a Congregate Care Medication Error Report form from the Arizona Department of Child Safety, designed to document and track medication errors in child care settings. The form is labeled as Exhibit IV and dated 05/24, and it is subject to confidentiality requirements. The document provides a structured template for reporting medication administration incidents, with sections for incident details, type of medication error, description of the incident, immediate actions taken, and follow-up prevention measures.
The form allows for comprehensive documentation of medication errors, including various types such as medication given to the wrong person, wrong dose, missed doses, medication not given at the right time, and other potential mistakes. It includes checkboxes for different error types, spaces for detailed incident description, and notification sections for DCSS, pharmacy, and physicians. The form is intended to help the agency track, investigate, and prevent medication administration errors in congregate care settings, with a focus on improving patient safety and care quality.
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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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