Form NDP4 "Level 2 or Level 3 Medication Error Report" - Alabama

What Is Form NDP4?

This is a legal form that was released by the Alabama Department of Mental Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 5, 2019;
  • The latest edition provided by the Alabama Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NDP4 by clicking the link below or browse more documents and templates provided by the Alabama Department of Mental Health.

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Download Form NDP4 "Level 2 or Level 3 Medication Error Report" - Alabama

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12/5/2019 NDP LEVEL 2 OR LEVEL 3 MEDICATION ERROR REPORT
NDP 4
Mandatory Form
CONFIDENTIAL FOR QUALITY ASSURANCE PURPOSES ONLY
TO BE COMPLETED BY THE MAS NURSE (RN/LPN)
SEND TO ADMH NDP OFFICE ONLY
Today’s Date ______________
Occurrence Date ______________ Occurrence Time ________A/P
Check One:
 Level 2
 Level 3
DIVISION:  DD
 MI
 SA
Client Name/Number _______________________________________
Staff Involved _____________________________________________ RN/LPN/MAC/Other* (Circle One)
Supervising Nurse _______________________________________ MAS RN/LPN Contacted?  Y  N
Agency ________________________________________________
Phone # (
)____ ________________
Location __________________________________________ (Agency/Group Home/Program Name/ County)
Prescribing Practitioner Name/Credentials____________________________________ Contacted?  Y  N
TYPE of ERROR
List all Medications Involved
Provide detail description of what occurred including # of errors and cause of error
 Wrong person
 Wrong medicine
 Wrong dose
 Wrong route
 Wrong time
 No documentation
 Wrong reason
 Missed Dose
 Other* (Explain)
Consumer Outcome (What happened to the consumer? Be descriptive, from notification to
resolution)
Action(s) Taken by the Nurse (What did the nurse do? Be descriptive, from notification to
resolution)
ALL RETRAINING MUST BE DOCUMENTED ON THE MED ADMIN AUDIT FORM
Person completing report _______________________________________ RN/LPN DATE ____________
Definitions: Level 2- error occurred that required treatment through an ER/ED/ or unplanned MD visit
Level 3- Error occurred that required hospitalization, permanent Loss, or death
NDP OFFICE USE ONLY
12/5/2019 NDP LEVEL 2 OR LEVEL 3 MEDICATION ERROR REPORT
NDP 4
Mandatory Form
CONFIDENTIAL FOR QUALITY ASSURANCE PURPOSES ONLY
TO BE COMPLETED BY THE MAS NURSE (RN/LPN)
SEND TO ADMH NDP OFFICE ONLY
Today’s Date ______________
Occurrence Date ______________ Occurrence Time ________A/P
Check One:
 Level 2
 Level 3
DIVISION:  DD
 MI
 SA
Client Name/Number _______________________________________
Staff Involved _____________________________________________ RN/LPN/MAC/Other* (Circle One)
Supervising Nurse _______________________________________ MAS RN/LPN Contacted?  Y  N
Agency ________________________________________________
Phone # (
)____ ________________
Location __________________________________________ (Agency/Group Home/Program Name/ County)
Prescribing Practitioner Name/Credentials____________________________________ Contacted?  Y  N
TYPE of ERROR
List all Medications Involved
Provide detail description of what occurred including # of errors and cause of error
 Wrong person
 Wrong medicine
 Wrong dose
 Wrong route
 Wrong time
 No documentation
 Wrong reason
 Missed Dose
 Other* (Explain)
Consumer Outcome (What happened to the consumer? Be descriptive, from notification to
resolution)
Action(s) Taken by the Nurse (What did the nurse do? Be descriptive, from notification to
resolution)
ALL RETRAINING MUST BE DOCUMENTED ON THE MED ADMIN AUDIT FORM
Person completing report _______________________________________ RN/LPN DATE ____________
Definitions: Level 2- error occurred that required treatment through an ER/ED/ or unplanned MD visit
Level 3- Error occurred that required hospitalization, permanent Loss, or death
NDP OFFICE USE ONLY