"Incident Response Improvement System Medication Error Incident Report Form" - North Carolina

Incident Response Improvement System Medication Error Incident Report Form is a legal document that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina.

Form Details:

  • The latest edition currently provided by the North Carolina Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download "Incident Response Improvement System Medication Error Incident Report Form" - North Carolina

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Page - 1 -
Corporation:
NAME
Name and Title of Person completing this form:
TITLE
Local Facility/Unit/Group Home
NPI Number:
Name:
License Number:
Director:
Physical Address:
Mailing Address:
City:
Zip Code:
(
)
-
Phone Number:
(
)
-
Fax Number:
E mail address:
County where services provided:
Host LME:
County of Residence:
Home LME:
Page - 1 -
Corporation:
NAME
Name and Title of Person completing this form:
TITLE
Local Facility/Unit/Group Home
NPI Number:
Name:
License Number:
Director:
Physical Address:
Mailing Address:
City:
Zip Code:
(
)
-
Phone Number:
(
)
-
Fax Number:
E mail address:
County where services provided:
Host LME:
County of Residence:
Home LME:
Page - 2 -
Date and Location
o
Date of Incident:
Unable to determine at this time
Time of Incident:
Date Provider Learned of Incident:
m
m
m
Yes
No
N/A
Was the consumer under the care of the reporting provider?
m
m
m
Yes
No
N/A
Was a Licensed Residential Service being provided?
Location of the Incident:
m
Consumer's Home
m
Friend’s home
m
Group home/Supported living facility
m
Home of Family Member
m
Hospital
m
School
m
Service facility
m
State Facility
m
Work
m
Unknown
m
Other
m
Community
Explain 'Other' in Comments
Other People Involed:
Page - 3 -
o
Friend
o
Friend of Family
o
Other Consumer
o
Family Member
o
Staff
o
Stranger
o
No one
o
Unknown
o
Other
Explain 'Other' in Comments
Does this incident include an allegation against the facility?
m
m
Yes
No
Will this allegation require a submission of a Consumer Incident Report?
m
m
Yes
No
Service Types Provided At the Time of the Incident:
m
m
m
Yes
No
N/A
Was the consumer under the care of the reporting provider?
m
m
m
Yes
No
N/A
Was a Licensed Residential Service being provided?
Service:
License#:
m
m
m
Yes
No
N/A
Was a Non-Residential Licensed Service being provided?
Service:
License#:
m
m
m
Yes
No
N/A
Was an Un-Licensed Service being provided?
Service:
First
MI
Last
Consumer's Name:
Page - 4 -
o
Address Unknown
Address where Incident Occurred:
Address1:
Address2:
City:
State:
Zip:
Location:
LME Client Record Number:
o
Date of Birth unknown
Consumer's Date of Birth:
m
m
Male
Female
Gender:
o
Unknown
Height:
ft
in
o
Unknown
Weight:
lbs
o
o
None
None
Dates of Last 2 Medical Exams:
Diagnoses:
Enter up to 5 different diagnoses starting with the primary diagnosis.
Current Medications:
Medical Diagnosis:
m
m
m
Yes
No
Unknown
Does consumer have TBI (Traumatic Brain Injury)?
m
m
m
Yes
No
Unknown
Is consumer receiving ICF-MR/DD services?
m
m
m
Yes
No
Unknown
Does consumer receive CAP-MR/DD funding?
Page - 5 -
m
m
m
Yes
No
Unknown
Comprehensive Waiver?
m
m
m
Yes
No
Unknown
Supports Waiver?
m
m
m
Yes
No
Unknown
Self-Directed Waiver?
m
m
m
Yes
No
Unknown
Innovations Waiver?
m
m
m
Yes
No
Unknown
Is this person in the Money Follows the Person program?
Treatments
m
m
Did this incident result in or is it likely to result in permanent physical or
Yes
No
psychological impairment?
Has this incident resulted in or is it likely to result in a danger to or concern to
m
m
Yes
No
the community or a report in a newspaper, television or other media?
Was the consumer treated by a licensed health
m
m
m
Yes
No
Unknown
care professional for the incident?
Date
If hospitalized ...
m
m
m
Yes
No
Unknown
was it for a medical condition?
m
m
m
Yes
No
Unknown
was it for a MH/DD/SAS issue?
Date
m
m
Is the consumer enrolled in an opioid treatment program, (methadone
Yes
No
maintenance)? If 'Yes', complete the entries in the following box.
Methadone Maintenance
1. Date of Admission to Methadone Maintenance Treatment
2. Date of Initial Methadone dosage
3. Initial Methadone dose received
mg
4. Date of last Methadone dosage prior to incident:
5. Last Total Methadone dose received prior to death
mg
Date
m
m
Yes
No
Dosed at Clinic?
m
m
Yes
No
Given Take-Homes?
6. Total Methadone dose received on the date of death (if different from above)
m
m
Yes
No
Dosed at Clinic?
m
m
Yes
No
Given Take-Homes?
7. Name of consumer's methadone treatment center physician
Mental Health Services