HILL COUNTRY COMMUNITY MHMR CENTER
CONSUMER NAME:
MEDICATION ERROR REPORT
CASE NUMBER:
Date &Time Discovered____________________ Date & Time Occurred_____________________
Center Reporting Error: ____________________________________________________________
Note: A dropped pill is not a medication error and should be documented on an Incident Form.
Location of Error:
cinilC HM ‫ٱ‬
cinilC RM ‫ٱ‬
emoH puorG ‫ٱ‬
emoH etavirP ‫ٱ‬
xoteD ‫ٱ‬
xT laitnediseR ‫ٱ‬
emoH retsoF ‫ٱ‬
baH yaD ‫ٱ‬
__________:rehtO ‫___ٱ‬
Consumer Status:
SCH/RM ‫ٱ‬
viLmHxT/RM ‫ٱ‬
ytinummoC/RM ‫ٱ‬
FCI/RM ‫ٱ‬
esubA ecnatsbuS ‫ٱ‬
remusnoc HM ‫ٱ‬
ICE ‫ٱ‬
dlihC ‫ٱ‬
Medication and Directions
Error Type:
noissimO ‫ٱ‬
tneitaP gnorW ‫ٱ‬
esoD gnorW ‫ٱ‬
emiT gnorW ‫ٱ‬
etuoR gnorW ‫ٱ‬
noitacideM gnorW ‫ٱ‬
tnuoC tcerrocnI ‫ٱ‬
‫ٱ‬Documentation Error
Where in Medication Process did
Error Occur?
‫ٱ‬Supervision
noitatnemucoD ‫ٱ‬
)ylno esrun( gnibircsnarT ‫ٱ‬
A ‫ٱ‬dministering (nurse only)
___________________rehtO ‫ٱ‬
Medication and Directions
Description: _______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Staff Signature:
Date/Time:
Supervisor or Director Signature:
Date/Time:
To Be Completed By Local Administration
Subunit: _________________________
Family/Guardian Notified: _____________________________________ Date/Time: ____________________
Comments: _________________________________________________________________________________
___________________________________________________________________________________________
Nurse Notified: [] No (documentation error only) [] Yes (all other med errors) Date/Time: _______________
Instructions from Nurse:_______________________________________________________________________
Other Action Taken At Time of Discovery: _______________________________________________________
__________________________________________________________________________________________
For Nurse: ________________________________________________________________________________
Physician Notified? [] No [] Yes Date/Time: _______________ Physician Name________________________
Orders given by physician? [] No [] Yes:_________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Document in record/chart as telephone order and obtain signature in timely manner.)
Date this report faxed by ADSO: ____________ Signature of ADSO:___________________________________
For Director of Nursing Use:
Error Resulted in:
[] did not impact consumer [] impacted consumer, no harm [] required monitoring consumer
[] required minor treatment/first aid [] required visit with physician [] required ER visit
Recommendation:___________________________________________________________________________
__________________________________________________________________________________________
DON Signature: _________________________________________ ____Date/Time: _____________________
NURSING: MR
FORM NUMBER:
Send the original to:
Director of Nursing, 819 Water Street #300, Kerrville, TX. 78028
REVISED: 3/16/06