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Medication Error Report Form Template

Efficiently report medication errors and enhance patient safety

When a medication error occurs, timely reporting is essential for patient safety and care quality. This Medication Error Report Form Template is designed to help healthcare professionals accurately document incidents, ensuring clear communication with the appropriate authorities. By using this form, you can streamline your reporting process, enhance accountability within your team, and contribute to a culture of safety and transparency. Plus, your reports will be compliant with industry standards and help prevent future errors. Start enhancing your reporting today with our live template.

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Full name (optional)
Role or title
Email (optional)
Date of report
You are submitting this report as:
Staff member
Patient
Family or caregiver
Visitor
Other/Unknown
Prefer not to say
Date of incident
Approximate time of incident
Location of incident (unit/area)
Stage in the medication process (select all that apply)
Prescribing
Transcribing
Dispensing
Preparation
Administration
Monitoring
Storage
Other/Unknown
Type of medication error (select all that apply)
Did the error reach the patient?
Yes
No
Unknown
Medication name (generic or brand)
Intended dose
Actual dose dispensed/administered (if applicable)
Intended route
Patient age band (optional)
What was the outcome for the patient?
Near miss (did not reach patient)
Reached patient but no harm
Required monitoring or intervention to prevent harm
Temporary harm
Permanent harm
Death
Unknown/Not assessed
Immediate actions taken (select all that apply)
Please Specify:
Contributing factors (select all that apply)
Was a barcode scan or independent double-check performed?
Yes
No
Not applicable
Unknown
Brief description of what happened (no names)
What could help prevent a recurrence?
Do you consent to follow-up contact if clarification is needed?
Yes
No
Signature
Date
I affirm that the information provided is accurate to the best of my knowledge.
True
False
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When to use this form

Use this form right after you spot a medication mistake or near miss in any care setting. Nurses, pharmacists, and providers can document wrong dose, wrong patient, omitted dose, or expired medication. It is also useful when barcode scanning catches an issue before it reaches the patient. Timely reports help your team fix the process, meet policy, and prevent repeat events. If home med lists are out of date, attach an updated Medication reconciliation form. For urgent handoffs to a provider or pharmacy, pair your report with an SBAR Form so the situation, background, assessment, and recommendation are clear. To verify orders and administrations, reference the Medication record form.

Must Ask Medication Error Report Questions

  1. What happened, and was it a near miss or did it reach the patient?

    Classifying the event type and stage (prescribing, dispensing, administering) focuses your review and trend analysis. It also guides urgency and follow-up, especially if harm is possible.

  2. When and where did it occur (date, time, unit or clinic, and exact location)?

    Precise time and place help trace staffing, workload, and system factors at that moment. This detail makes it easier to recreate the steps and find breakdowns.

  3. Which medication was involved (name, strength, dose, route, formulation, lot, and expiry)?

    Complete product details let pharmacy confirm look-alike or sound-alike risks and remove suspect stock. They also support recalls and corrections in the chart and dispensing systems.

  4. What was the patient impact, and what actions did you take?

    Documenting signs, symptoms, monitoring, and treatment shows whether harm occurred and what is still needed. Recording who you notified and using SBAR for the handoff reduces delays and miscommunication.

  5. What contributing factors did you notice, and what prevention steps do you recommend?

    Listing causes (unclear orders, similar packaging, interruptions, equipment issues) points to solutions your team can act on. If a deeper review is required, start a Case report form to capture the investigation and outcomes.

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