Download ua medication error report form - University of Arizona College of

University of Arizona, College of Pharmacy
Student and Preceptor Manual for PhPr 803 F & G - Applied Evidence-Based Pharmacy Practice
UA MEDICATION ERROR REPORT FORM
The National Coordinating Council for Medication Error Reporting defines a "medication error" as follows:
"A medication error is any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the health care professional, patient,
or consumer. Such events may be related to professional practice, health care products,
procedures, and systems, including prescribing; order communication; product labeling,
packaging, and nomenclature; compounding; dispensing; distribution; administration; education;
monitoring; and use."
POTENTIAL MEDICATION CONCERN OR ERROR INFORMATION
Med Error Submission #:
(up to 3 letters or numbers, no spaces or periods)
Date of event:
(M/d/yy)
Time of event:
(h:mm am/pm)
Setting:
Community Pharmacy (drop down list)
Order as written by Health Care Provider or Name of Drug Involved (limit 200 spaces)
Brief Facts of the Event (limit 300 spaces)
Classify Patient Outcome:
No error but capacity to cause error (drop down list)
Describe Patient Outcome. (limit 100 spaces)
Who was notified of this concern or error? (limit 100 spaces)
Student's name:
Date of report:
Evaluating preceptor's name:
(M/d/yy)