ISMP Medication Errors Reporting Program

ISMP Medication Errors Reporting Program
ISMP is a federally certified Patient Safety Organization and an FDA MEDWATCH partner
Reporters should not provide any individually identifiable health information, including names of practitioners,
names of patients, names of healthcare facilities, or dates of birth (age is acceptable).
Date and time of event:
Please describe the error. Include description/sequence of events, type of staff involved, and work environment (e.g., code situation,
change of shift, no 24-hr. pharmacy, floor stock). If more space is needed, please attach a separate page.
Did the error reach the patient? Yes No
Was the incorrect medication, dose, or dosage form administered to or taken by the patient? Yes No
Circle the appropriate Error Outcome Category (select one—see back for details): A B C D E F G H I
Describe the direct result of the error on the patient (e.g., death, type of harm, additional patient monitoring). __________________________________
Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar names, distractions). _________________________________
___________________________________________________________________________________________________________________________
Indicate the location of the error (e.g., hospital, community pharmacy, clinic, nursing home, patient’s home) . ___________________________________
What type of staff or healthcare practitioner made the initial error? ____________________________________________________________________
Indicate if other practitioner(s) were also involved in the error (type of staff perpetuating error). _____________________________________________
What type of staff or healthcare practitioner discovered the error or recognized the potential for error? _______________________________________
How was the error (or potential for error) discovered/intercepted? ___________________________________________________________________
If available, provide patient age, gender, diagnosis. Do not provide any patient identifiers. _________________________________________________
________________________________________________________________________________________________________________________
Please complete the following for the product(s) involved. (If more space is needed for additional products, please attach a separate page.)
Brand/Product Name
(If Applicable)
Generic Name
Manufacturer
Labeler
Dosage Form
Strength/Concentration
Type and Size of Container
Product #1 Product #2
Reports are most useful when relevant materials such as product label, copy of prescription/order, etc., can be reviewed.
Can these materials be provided? Yes No Please specify: ______________________________________________________________
Suggest any recommendations to prevent recurrence of this error, or describe policies or procedures you instituted or plan to institute to prevent
future similar errors. _________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
( ) ( )
Name and Title/Profession Telephone Number Fax Number
Facility/Address and Zip
E-mail
Address/Zip (where correspondence should be sent)
Please check the box that applies: Consumer Licensed Healthcare Practitioner Student/Technician
Copies of reports, without any identifying information, will be sent to third parties such as the manufacturer/labeler and to the Food and Drug Administration
(FDA).You have the option of including your name on these copies.
ISMP may release my identity to these third parties as follows (check boxes that apply):
FDA The manufacturer and/or labeler as listed above Anonymous to all third parties
Signature
Date
Return to: ISMP, 200 Lakeside Dr., Ste. 200, Horsham, PA 19044 Fax: 215-914-1492
Submit via the web at: www.ismp.org/merp Phone: 800-Fail-Saf(e) (800-324-5723)
Date Received by ISMP
File Access Number
©ISMP 2009
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NCC MERP Index for
Categorizing Medication Errors
NCC MERP Index for Categorizing
Medication Errors Algorithm
© 2003 National Coordinating Council for Medication Error Reporting and Prevention
Full-size copies are available: INDEX—www.nccmerp.org/010612_color_index.pdf; ALGORITHM—www.nccmerp.org/010612_color_algo.pdf
Definitions from ISMP and NCC MERP
Hazardous Condition (ISMP)
A condition or situation that could lead to or cause an error
(i.e., Category A).
Near Miss (ISMP)
A medication error that was detected and corrected before it
reached the patient (i.e., Category B).
Harm (NCC MERP)
Impairment of the physical, emotional, or psychological function
or structure of the body and/or pain resulting therefrom.
Monitoring (NCC MERP)
To observe or record relevant physiological or psychological
signs.
Intervention (NCC MERP)
May include change in therapy or active medical/surgical
treatment.
Intervention Necessary to Sustain Life (NCC MERP)
Includes cardiovascular and respiratory support (e.g., CPR,
defibrillation, intubation, etc.).
Submit a Report to the ISMP Medication Errors Reporting Program (MERP)
Mail: Internet: Phone:
ISMP www.ismp.org/merp 800-Fail-Saf(e) (800-324-5723)
200 Lakeside Drive
Suite 200 Email: Fax:
Horsham, PA 19044 merp@ismp.org 215-914-1492
About ISMP
The Institute for Safe Medication Practices (ISMP) is the nation’s only nonprofit, charitable organization devoted entirely to medication
error prevention. ISMP provides independent recommendations for the safe use of medications to healthcare professionals, government
agencies, accrediting organizations, the pharmaceutical industry and consumers. Its effective error prevention strategies, recognized
and respected worldwide, are based on information gained through analysis of reports to a voluntary national program as well as onsite
visits to individual healthcare organizations. ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality
for patient safety data and error reports it receives. For more information or to make a donation to support ISMP’s lifesaving work,
visit www.ismp.org.
A federally certified
Patient Safety Organization
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