Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER)
Medication Error Reporting Form
(A blame free reporting tool)
Please tick the appropriate box. All fields must be filled except details of reporter which is optional.
he appropriate box. All fields are mandatory.
1. Date of event: _____________ 2. Location of event:
Time of event: _____________ Ward OPD Pharmacy Others ___________
3. Type of error: 4. Patient details:
Prescribing Dispensing Age: Gender:
Administration Others (specify) Diagnosis:
------------------------
5. Description of the event: (how did the event occur and how was it detected?)
6. Details of medicines involved in the event: 7. Did the error reach the patient?
Yes No
Dosage
S. No. Generic Name Strength Frequency
Form
8. Outcome of the event:
No error Error, harm
A. Events have E. Temporary harm
potential to requiring treatment
cause error
9. Possible causes & contributing factors: F. Temporary harm
Error, No harm
requiring
B. Error did not hospitalization
Lack of knowledge / Unavailable patient reach patient
experience information G. Permanent harm
C. No harm
Illegible prescription Peak hour
H. Near death event
D. No harm but
Look alike / sound alike Miscommunication requires Error, death
medication monitoring I. Death
Failure to adhere to work
Wrong labeling / instruction procedure 10. Details of reporter: (optional)
Use of abbreviations Others ____________ Name:
Designation:
Mobile No:
11. Intervention done:
Administered antidote Changed to correct drug / dose / frequency No action needed
Education / training provided Communication process improved Others (specify)
Informed staff who made error Policy / procedure changed / instituted
Report All Medication Errors
Its blame free
What is medication error?
Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or
patient harm, while the medication is in the control of health care professional, patient or consumer. Such
events may be related to professional practice, health care products, procedures and systems including
prescribing, dispensing and administration.
Examples of medication errors
Therapeutically incorrect order (drug / dose / frequency / route)
Illegible / incomplete prescription
Abbreviations, improper use of decimal points (missing leading zero /unnecessary trailing zero)
Noncompliance with order while dispensing / administration
Use of deteriorated / expired products
Why should I report?
Medication errors are an important preventable cause of morbidity and mortality. If errors are reported,
corrective measures can be undertaken to prevent them. This will improve the safety of the patients.
Moreover, medication error reporting is blame free.
Are there issues concerning the confidentiality of the patient / person committing error?
There are absolutely no issues regarding confidentiality as the identifier information (like name, hospital
number) of either the patient or the person committing the error need not be reported. The details of the
reporter are optional and when furnished, will be kept confidential.
What to report?
All medication errors should be reported. Even potential errors (events that have potential to cause error) can
be reported. A few examples of medication errors are given above.
Please do remember that there is no blame and you can report any medication error committed by anyone.
Who can report?
Any health care professional (doctors, nurses, pharmacists and allied health care professionals) can report
medication errors.
When to report?
Whenever you come across a medication error, committed by self or anyone, you can report. There is no strict
timeline within which it should be reported. But it is advisable to report immediately.
How to report?
Please fill in the medication error reporting form completely (details of reporter is optional) and send it by email
to JIPMER Quality Council (E-mail : mereports@gmail.com). The medication error reporting forms are freely
available in all wards / OPDs and can also be downloaded from JIPMER website (www.jipmer.edu.in).
