Form S Medical Misadministration Report - Alabama

Form S or the "Medical Misadministration Report" is a form issued by the Alabama Department of Public Health.

A PDF of the latest Form S can be downloaded below or found on the Alabama Department of Public Health Forms and Publications website.

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Form S
ALABAMA DEPARTMENT OF PUBLIC HEALTH
MEDICAL MISADMINISTRATION REPORT
1. Licensee Name
2. License No.
3. City
4. State
5. Event Date
6. Discovery Date
7. Report Date
9. Did the Misadministration Involve Iodine? G Yes
8. Type of Misadministration
G No
G
G
10. Number of patients who received misadministrations
Wrong pharmaceutical
Dosage differs from prescribed dosage by 50%
G
G
under this report.
Wrong patient
Wrong route of administration
11. Procedure Prescribed
11(a). Dosage Prescribed
12. Dosage Administered
G
G
Millicuries
Isotope
Chemical form
Study
Millicuries
Isotope
Chemical form
Study
No clinical procedure
Ultrasound study
G
G
Nuclear medicine study
CT study
G
(complete 11(a) and 12.)
MRI study
G
G
X-Ray study
Other
13. Who or What Precipitated the Misadministration
G
G
Nuclear Medicine Physician
Hot Lab Technologist
G
G
Referring Physician
Imaging Technologist
G
G
Ward Nurse
Clinic Receptionist
G
G
Nuclear Pharmacy
Scheduling Technologist
G
____________________________________________________________________________
Patient
G
Name of Nuclear Pharmacy
City
State
Other
14. Error
Hot Lab
Referral
Administration
Other
G
G
G
G
G
Mislabeled a Syringe
Selected Wrong Vial
Misunderstood Referring
Selected Wrong Patient
Specify
G
When Drawing Dosage
Physician’s Request
___________________
Mislabeled a Vial or
G
G
Vial Shield
Set Dose Calibrator
Requested Wrong Study
___________________
G
G
Improperly
Requested Wrong Study
Reconstituted Wrong
___________________
G
G
Reagent Kit
Misread Dose Calibrator
Brought Wrong Patient to
___________________
G
G
G
Requested Study for
Clinic
Placed Reconstituted Vial
Misunderstood
___________________
G
Wrong Patient
Selected Wrong Syringe
in Wrong Shield
Radiopharmaceutical or
___________________
Dosage Order
From Dosage Cart
15. Contributing Factors
16. Actions Taken to Prevent Recurrence
G
G
G
G
Student Technologist
Requisition Not Checked
Implement New Procedures For
Improve Supervision of Personnel
G
G
G
New Employee
Patient Chart Not Checked
Verification of Request
G
G
G
G
No Action
Foreign Language
New Procedure
Radiopharmaceutical Labeling
G
G
and Handling
Patient Incoherent or
Heavy Workload
G
G
Other ______________________
G
Verification of Patient ID
Unconscious
Other ______________________
________________________
G
ID Not Checked
________________________
G
________________________
Reinstruct Personnel
________________________
G
________________________
Reprimand Personnel
G None Apparent
G See Abstract
17. Effect on Patient(s)
(Continued on Reverse)
Form S
ALABAMA DEPARTMENT OF PUBLIC HEALTH
MEDICAL MISADMINISTRATION REPORT
1. Licensee Name
2. License No.
3. City
4. State
5. Event Date
6. Discovery Date
7. Report Date
9. Did the Misadministration Involve Iodine? G Yes
8. Type of Misadministration
G No
G
G
10. Number of patients who received misadministrations
Wrong pharmaceutical
Dosage differs from prescribed dosage by 50%
G
G
under this report.
Wrong patient
Wrong route of administration
11. Procedure Prescribed
11(a). Dosage Prescribed
12. Dosage Administered
G
G
Millicuries
Isotope
Chemical form
Study
Millicuries
Isotope
Chemical form
Study
No clinical procedure
Ultrasound study
G
G
Nuclear medicine study
CT study
G
(complete 11(a) and 12.)
MRI study
G
G
X-Ray study
Other
13. Who or What Precipitated the Misadministration
G
G
Nuclear Medicine Physician
Hot Lab Technologist
G
G
Referring Physician
Imaging Technologist
G
G
Ward Nurse
Clinic Receptionist
G
G
Nuclear Pharmacy
Scheduling Technologist
G
____________________________________________________________________________
Patient
G
Name of Nuclear Pharmacy
City
State
Other
14. Error
Hot Lab
Referral
Administration
Other
G
G
G
G
G
Mislabeled a Syringe
Selected Wrong Vial
Misunderstood Referring
Selected Wrong Patient
Specify
G
When Drawing Dosage
Physician’s Request
___________________
Mislabeled a Vial or
G
G
Vial Shield
Set Dose Calibrator
Requested Wrong Study
___________________
G
G
Improperly
Requested Wrong Study
Reconstituted Wrong
___________________
G
G
Reagent Kit
Misread Dose Calibrator
Brought Wrong Patient to
___________________
G
G
G
Requested Study for
Clinic
Placed Reconstituted Vial
Misunderstood
___________________
G
Wrong Patient
Selected Wrong Syringe
in Wrong Shield
Radiopharmaceutical or
___________________
Dosage Order
From Dosage Cart
15. Contributing Factors
16. Actions Taken to Prevent Recurrence
G
G
G
G
Student Technologist
Requisition Not Checked
Implement New Procedures For
Improve Supervision of Personnel
G
G
G
New Employee
Patient Chart Not Checked
Verification of Request
G
G
G
G
No Action
Foreign Language
New Procedure
Radiopharmaceutical Labeling
G
G
and Handling
Patient Incoherent or
Heavy Workload
G
G
Other ______________________
G
Verification of Patient ID
Unconscious
Other ______________________
________________________
G
ID Not Checked
________________________
G
________________________
Reinstruct Personnel
________________________
G
________________________
Reprimand Personnel
G None Apparent
G See Abstract
17. Effect on Patient(s)
(Continued on Reverse)
18. Abstract (Include a description of preventative actions taken) Attach additional sheets if necessary.
Certification: The undersigned official executing this report on behalf of the licensee named in Item 1, certifies that
19.
this report is prepared in conformity with Chapter 420-3-26, and that all information contained herein, including any
supplements attached hereto, is true and correct to the best of our knowledge and belief.
________________________________
______________________________________
______________________
Signature of Certifying Official
Printed Name and Title of Certifying Official
Date
For Agency Use Only
Reportable to NRC? G Yes
G No
Incident Number:
Reviewed By:
Form S
(Continued on Reverse)
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