Medical Error Report Form

This report form is designed to allow team members to report medical errors or patient injuries. Reports are anonymous and reviewed by the Partner Veterinary hospital stewards and medical team. Medical incidents are categorized, and training opportunities are developed from the categories identified. Accurate reporting of medical errors helps us to uphold patient safety.  Thank you for taking the time to report this event. Please answer the questions below to the best of your ability. 

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Incident Date / Incident Time

Date

Time

Location

• Emergency
• Surgery
• Inpatient
• Urgent Care
• Neurology
• Cardiology
• Internal Medicine
• Oncology
• Other

When was it discovered?

Incident Type

• Medication Error – Incorrect Patient
• Medication Error – Incorrect Medication Administered
• Medication Error – Incorrect Time of Administration
• Medication Error – Incorrect Dosage of Medication
• Medication Error – Incorrect VOLUME of Fluids
• Medication Error – Incorrect Route of Administration
• Medication Error – Incorrect Dilution of Medication
• Medication Error – Incorrect FORMULATION of CRI
• Medication Error – Expired Medication Administered
• Treatment Error – Incorrect Technique Utilized
• Treatment Error – Failure to Provide Treatment
• Treatment Error – Incorrect Patient Receiving Treatment (Non-Medication)
• Treatment Error – Inadequate Patient Monitoring
• Prescribing/Dispensing Error – Incorrect Prescription Dispensed to Patient
• Patient Injury
• Other

Please provide more explanation about the incident and how it happened.

Layout

Ordered Medication

Drug Name(Brand)

Drug Name(Generic)

Dosage

Route (Oral, Sublingual, IM, IV, Inhalation, Topical, Other)

Directions for Use

Intended to Administer

Intended to Administer

Intended to Administer

Intended to Administer

Intended to Administer

Error in Administration

Error in Administration

Error in Administration

Error in Administration

Error in Administration

If medication error selected above, please provide details below relevant to the error. If not a medication error, proceed to next question.

If medication error reported, check all that apply:

• ASPCA Poison Control was consulted regarding medication error
• Chief Medical Officer or Medical Director was contacted regarding medication error
• Owners were contacted regarding medication error

What is the outcome or result of the incident?

• Patient was not harmed/affected
• Patient required monitoring for adverse effects, but did not require treatment
• Patient required treatment(s) within first 6 hours of event
• Patient required additional hospitalization time for event
• Patient was permanently harmed
• Patient died
• Other

Other

Please provide an explanation in paragraph format about the outcome of the incident.

What are the possible reasons or contributor factors why did this incident happened?

• Missing or incorrect information
• Drug details are incorrect
• Miscommunication between health care workers
• Drug label and packaging issues
• Incorrect drug solution or content
• Staffing issues
• Environmental factors
• Lack of education
• Lack of training
• Other

Other

Please explain more in details about the options you selected above (previous question).

What are the things that health care workers should do in order to prevent this type of incident?

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