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
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