"Medication Error Report Form"

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Medication Error Report Form
Student: _________________________________________________________________________________
DOB: _____________________
School Building: __________________________________________________________________________________ Grade: _____________
Date of Error: ___________________ Medication: __________________________________________________________________________
Medication Dosage: ________________________________ Time to be given: _____________________ Route: _________________________
State Reason For Report: (failure to administer medication to the student, failure to administer medication within the designated time, failure to
administer the correct dosage of medication, failure to administer medication by proper route, failure to administer medication according to
generally accepted standards of practice, administering the wrong medication to the wrong student, administering medication without parent
authorization, administering a prescription medication to a student who does not have a prescription)
Medication Errors DO NOT include: unusual situations or incidents where students refuse to consume or are unable to tolerate medication
administration, lack of supply of medication from the parent, or a medication held by a parent/guardian. Careful notation of these situations should
be made on the back of the medication administration record or incident form, if applicable, and parents/guardian notification per school
procedure.
Action Taken/Intervention:
School Nurse Name (Print): ________________________________________
Notified: _________ Yes __________ No
Date: ____________________ Time: ____________________
Name of Parent/Guardian notified (if applicable):
___________________________________________________ Date and Time: ___________________
Student’s physician notified (if applicable):
___________________________________________________ Date and Time: ___________________
Building Administrator Signature:
___________________________________________________ Date: ___________________________
Witness(s): ______________________________________________
Name of Person Preparing Report (Please Print): ___________________________________________
Signature of Person Preparing Report: _______________________________________ Date: _______
Follow Up Skills Check Completed By School Nurse: __________ Yes __________No
Follow Up Care/Contact: ___________________________________________________________________________________________
________________________________________________________________________________________________________________
Signature of School Nurse Notified/Conducting Skills Check, Follow-Up Care: ________________________________________________
**************************************************************************************************************************************
This is an example of information needed in a medication error report. School determines policies and procedures who will be notified and in what order. The
form should be completed in ink. Do not use “white out”, correction tape, eraser, or pencil to correct recording errors. Draw a single line through the error, record
the correct information, and initial the corrected entry. The completed form is to be sent to the school nurse and a copy delivered to the school administrator to
be placed in a designated location defined by the school.
Medication Error Report Form
Student: _________________________________________________________________________________
DOB: _____________________
School Building: __________________________________________________________________________________ Grade: _____________
Date of Error: ___________________ Medication: __________________________________________________________________________
Medication Dosage: ________________________________ Time to be given: _____________________ Route: _________________________
State Reason For Report: (failure to administer medication to the student, failure to administer medication within the designated time, failure to
administer the correct dosage of medication, failure to administer medication by proper route, failure to administer medication according to
generally accepted standards of practice, administering the wrong medication to the wrong student, administering medication without parent
authorization, administering a prescription medication to a student who does not have a prescription)
Medication Errors DO NOT include: unusual situations or incidents where students refuse to consume or are unable to tolerate medication
administration, lack of supply of medication from the parent, or a medication held by a parent/guardian. Careful notation of these situations should
be made on the back of the medication administration record or incident form, if applicable, and parents/guardian notification per school
procedure.
Action Taken/Intervention:
School Nurse Name (Print): ________________________________________
Notified: _________ Yes __________ No
Date: ____________________ Time: ____________________
Name of Parent/Guardian notified (if applicable):
___________________________________________________ Date and Time: ___________________
Student’s physician notified (if applicable):
___________________________________________________ Date and Time: ___________________
Building Administrator Signature:
___________________________________________________ Date: ___________________________
Witness(s): ______________________________________________
Name of Person Preparing Report (Please Print): ___________________________________________
Signature of Person Preparing Report: _______________________________________ Date: _______
Follow Up Skills Check Completed By School Nurse: __________ Yes __________No
Follow Up Care/Contact: ___________________________________________________________________________________________
________________________________________________________________________________________________________________
Signature of School Nurse Notified/Conducting Skills Check, Follow-Up Care: ________________________________________________
**************************************************************************************************************************************
This is an example of information needed in a medication error report. School determines policies and procedures who will be notified and in what order. The
form should be completed in ink. Do not use “white out”, correction tape, eraser, or pencil to correct recording errors. Draw a single line through the error, record
the correct information, and initial the corrected entry. The completed form is to be sent to the school nurse and a copy delivered to the school administrator to
be placed in a designated location defined by the school.