ISMP Medication Errors Reporting Program
ISMP Medication Errors Reporting Program
ISMP Medication Errors Reporting Program
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<strong>ISMP</strong> <strong>Medication</strong> <strong>Errors</strong> <strong>Reporting</strong> <strong>Program</strong><br />
<strong>ISMP</strong> is a federally certified Patient Safety Organization and an FDA MEDWATCH partner<br />
Reporters should not provide any individually identifiable health information, including names of practitioners,<br />
names of patients, names of healthcare facilities, or dates of birth (age is acceptable).<br />
Date and time of event:<br />
Please describe the error. Include description/sequence of events, type of staff involved, and work environment (e.g., code situation,<br />
change of shift, no 24-hr. pharmacy, floor stock). If more space is needed, please attach a separate page.<br />
Did the error reach the patient? Yes No<br />
Was the incorrect medication, dose, or dosage form administered to or taken by the patient? Yes No<br />
Circle the appropriate Error Outcome Category (select one—see back for details): A B C D E F G H I<br />
Describe the direct result of the error on the patient (e.g., death, type of harm, additional patient monitoring). __________________________________<br />
Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar names, distractions). _________________________________<br />
___________________________________________________________________________________________________________________________<br />
Indicate the location of the error (e.g., hospital, community pharmacy, clinic, nursing home, patient’s home) . ___________________________________<br />
What type of staff or healthcare practitioner made the initial error? ____________________________________________________________________<br />
Indicate if other practitioner(s) were also involved in the error (type of staff perpetuating error). _____________________________________________<br />
What type of staff or healthcare practitioner discovered the error or recognized the potential for error? _______________________________________<br />
How was the error (or potential for error) discovered/intercepted? ___________________________________________________________________<br />
If available, provide patient age, gender, diagnosis. Do not provide any patient identifiers. _________________________________________________<br />
________________________________________________________________________________________________________________________<br />
Please complete the following for the product(s) involved. (If more space is needed for additional products, please attach a separate page.)<br />
Product #1 Product #2<br />
Brand/Product Name<br />
(If Applicable)<br />
Generic Name<br />
Manufacturer<br />
Labeler<br />
Dosage Form<br />
Strength/Concentration<br />
Type and Size of Container<br />
Reports are most useful when relevant materials such as product label, copy of prescription/order, etc., can be reviewed.<br />
Can these materials be provided? Yes No Please specify: ______________________________________________________________<br />
Suggest any recommendations to prevent recurrence of this error, or describe policies or procedures you instituted or plan to institute to prevent<br />
future similar errors. _________________________________________________________________________________________________________<br />
_____________________________________________________________________________________________________________________________<br />
( ) ( )<br />
Name and Title/Profession Telephone Number Fax Number<br />
Facility/Address and Zip<br />
E-mail<br />
Address/Zip (where correspondence should be sent)<br />
Please check the box that applies: Consumer Licensed Healthcare Practitioner Student/Technician<br />
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<br />
(FDA).You have the option of including your name on these copies.<br />
<strong>ISMP</strong> may release my identity to these third parties as follows (check boxes that apply):<br />
FDA The manufacturer and/or labeler as listed above Anonymous to all third parties<br />
Signature<br />
Date<br />
Return to: <strong>ISMP</strong>, 200 Lakeside Dr., Ste. 200, Horsham, PA 19044 Fax: 215-914-1492<br />
Submit via the web at: www.ismp.org/merp Phone: 800-Fail-Saf(e) (800-324-5723)<br />
Date Received by <strong>ISMP</strong><br />
File Access Number<br />
©<strong>ISMP</strong> 2009<br />
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NCC MERP Index for<br />
Categorizing <strong>Medication</strong> <strong>Errors</strong><br />
NCC MERP Index for Categorizing<br />
<strong>Medication</strong> <strong>Errors</strong> Algorithm<br />
© 2003 National Coordinating Council for <strong>Medication</strong> Error <strong>Reporting</strong> and Prevention<br />
Full-size copies are available: INDEX—www.nccmerp.org/010612_color_index.pdf; ALGORITHM—www.nccmerp.org/010612_color_algo.pdf<br />
Definitions from <strong>ISMP</strong> and NCC MERP<br />
Hazardous Condition (<strong>ISMP</strong>)<br />
A condition or situation that could lead to or cause an error<br />
(i.e., Category A).<br />
Near Miss (<strong>ISMP</strong>)<br />
A medication error that was detected and corrected before it<br />
reached the patient (i.e., Category B).<br />
Harm (NCC MERP)<br />
Impairment of the physical, emotional, or psychological function<br />
or structure of the body and/or pain resulting therefrom.<br />
Monitoring (NCC MERP)<br />
To observe or record relevant physiological or psychological<br />
signs.<br />
Intervention (NCC MERP)<br />
May include change in therapy or active medical/surgical<br />
treatment.<br />
Intervention Necessary to Sustain Life (NCC MERP)<br />
Includes cardiovascular and respiratory support (e.g., CPR,<br />
defibrillation, intubation, etc.).<br />
Submit a Report to the <strong>ISMP</strong> <strong>Medication</strong> <strong>Errors</strong> <strong>Reporting</strong> <strong>Program</strong> (MERP)<br />
Mail: Internet: Phone:<br />
<strong>ISMP</strong> www.ismp.org/merp 800-Fail-Saf(e) (800-324-5723)<br />
200 Lakeside Drive<br />
Suite 200 Email: Fax:<br />
Horsham, PA 19044 merp@ismp.org 215-914-1492<br />
About <strong>ISMP</strong><br />
The Institute for Safe <strong>Medication</strong> Practices (<strong>ISMP</strong>) is the nation’s only nonprofit, charitable organization devoted entirely to medication<br />
error prevention. <strong>ISMP</strong> provides independent recommendations for the safe use of medications to healthcare professionals, government<br />
agencies, accrediting organizations, the pharmaceutical industry and consumers. Its effective error prevention strategies, recognized<br />
and respected worldwide, are based on information gained through analysis of reports to a voluntary national program as well as onsite<br />
visits to individual healthcare organizations. <strong>ISMP</strong> is a federally certified patient safety organization (PSO), providing legal protection and confidentiality<br />
for patient safety data and error reports it receives. For more information or to make a donation to support <strong>ISMP</strong>’s lifesaving work,<br />
visit www.ismp.org.<br />
A federally certified<br />
Patient Safety Organization<br />
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