PLACE LABEL HERE
ADVERSE DRUG REACTION (ADR) FORM
Submission of this report does not constitute an admission that medical personnel
or the product caused or contributed to the event.
ADR DEFINITION- Any unexpected, unintended, undesired, or excessive response to a drug that: requires discontinuing the drug
(therapeutic or diagnostic); requires changing the drug therapy; requires modifying the dose (except for minor dosage adjustments);
necessitates admission to a hospital; prolongs stay in health care facility; necessitates supportive treatment; significantly complicates
diagnosis; negatively affects prognosis, or results in temporary or permanent hard, disability or death.
Additionally: Allergic reactions (an immunologic hypersensitivity occurring as the result of unusual sensitivity to a drug) and an
idiosyncratic reactions (abnormal susceptibility to a drug that is peculiar to the individual) are considered ADRs. Suspected ADRs
should also be documented and reported.
-
Mild ADR: no or minimal intervention required to prevent incapacity, i.e. drug held, discontinued or antidote given
Moderate ADR: requires initial or prolonged hospitalization or is life threatening.
Severe ADR: results in persistent incapacity or death (Notify Pharmacy in addition to Physician)
PHYSICIAN NOTIFICATION: IMMEDIATE if the ADR has harmed or potentially harmed the patient.
Suspected Medication(s):
____________________________ Dose___________ Route______ Time administered__________
____________________________ Dose___________ Route______ Time administered__________
Clinical Staff Review:
Patient weight ________kg
Serum Creatinine level________ (date_______)
Drug Allergies: NKA or ________________________________________________
Date Reaction Noted __________________ Time______________________
Reaction occurred prior to admission/visit?
 Yes
 No
Admission/visit due to this ADR?
 Yes
 No
Description of reaction:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Intervention/Treatment:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Resolution/Outcome:
_________________________________________________________________________________________________
Name of Physician notified __________________________________ Date________Time ______
Name of Pharmacist notified _________________________________Date________ Time ______
Clinical Staff Name (print)__________________________________ Ext._______
Signature_______________________________________________ Date_______ Time________
Physician Review:
 Yes
Based on this reaction, should patient be advised to avoid this drug in the future?  Yes
NEW Allergy:
 No
 No
________________________________________________________________________________________________
_________________________________________________________________________________________________
WHITE: Order section of Chart
*1-16153*
1
CANARY: Pharmacy, AFTER Physician review
FORM 1-16153 REV. 11/2012
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PLACE LABEL HERE
ADVERSE DRUG REACTION (ADR) FORM
______________
Date
___________________
Time
WHITE: Order section of Chart
*1-16153*
1
_________________________________
Physician Signature
__________
PID Number
CANARY: Pharmacy, AFTER Physician review
FORM 1-16153 REV. 11/2012
Page 1 of