DATAFORM 3 Medication Error and Near Miss Classification Form

WBDDATAFORM 3Medication Error and Near MissClassification Form1. Study ID Number: ____ ____-____ ____ ____ ____ ____2. Reviewer ID Number: ____ ____See below for codes3.4.Case # Script #__ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . _____ __ __ __ ___ . ___5.ME orNM6.Primary errorclassification7.Specify errorclass.8.Secondary errorclassification9.PersonResp.10.Otherperson(s) resp.11.Workresulting12.Leveloccurred13.Errorintercepted14.BywhomPage 1 of 2Center of Excellence for Patient Safety Research and Practice 5/27/05Dataform 3: Medication Error and Near Miss Classification Form Version 0.3

Codes for Question 51. Med error2. Near missCodes for Question 6 and 81. Illegible Order1.01 MD signature illegible1.02 Patient name illegible1.031.041.051.061.07Med name illegibleIllegible routeIllegible frequencyIllegible length of treatmentIllegible amount to be dispensed1.08 Entire prescription illegible1.09 Illegible dose or dose units1.10 Illegible strength or strength units1.11 Illegible date1.12 Illegible weight or weight1.13 Illegible directions for use2. Dose error2.01 Overdose2.02 Underdose2.03 Dose omitted (from order/when dispensed)2.04 Dose units omitted2.05 Dose form incorrect2.06 Extra dose(s)2.07 Missed dose(s) (not given/taken)2.08 Discrepancy in dose3. Route error3.01 Route omitted3.02 Route incorrect3.03 Discrepancy in route4. Frequency error4.01 Frequency omitted4.02 Frequency incorrect4.03 Discrepancy in frequency5. Length of Treatment Error5.01 ength of treatment omitted5.02 Length of treatment incorrect5.03 Discrepancy in length of treatment6. Directions Error6.01 Directions for use omitted6.02 Directions for use incorrect6.03 Directions for use incomplete6.04 Discrepancy in directions7. Strength Error7.01 Strength omitted7.02 Strength incorrect7.03 Strength incomplete7.04 Strength without units8. Amount to be dispensed error8.01 Amount to be dispensed omitted8.02 Amount to be dispensed incorrect8.03 Amount to be dispensed without units8.04 Amount to be dispensed units incorrect9. PRN without indication10. Weight Error10.01 Weight omitted10.02 Weight wrong10.03 Weight units missing11. Date Error11.01 Date omitted11.02 Date incorrect12. Inappropriate use of abbreviation12.01 Dose abbreviation12.02 Route abbreviation12.03 Frequency abbreviation12.04 Length of treatment abbreviation12.05 Directions abbreviation12.06 Strength abbreviation12.07 Amount abbreviation12.08 Weight abbreviation12.09 Drug name abbreviation13. Other, specify: __________________14. Substitution13.01 Wrong drug given13.02 Wrong patient received drug13.03 Wrong drug ordered15. Failure to recognize drug-drug interaction16. Inadequate follow-up of therapy17. Use of inappropriate drug18. Avoidable delay of treatment19. Patient had documented allergy to medicationprescribed20. Refill Error20.01 Refill amount omitted20.02 Refill amount incorrectCodes for Question 9, 10, and 141. Physician2. Nurse practitioner3. Physician’s assistant4. Nurse in office5. Pharmacist in office6. Pharmacist in pharmacy7. Parent/Legal guardian8. School nurse9. Babysitter/daycare provider10. Patient11. Other ___________________12. None13. Insurance14. Person who takes phone orders15. LMRCodes for question 11 (Choose all that apply)1. Patient contacted provider (phone)2. Patient contacted provider (email)3. Patient contacted RN (phone)4. Patient contacted RN (email)5. Provider contacted pharmacy6. Pharmacy contacted provider7. Patient contacted pharmacy8. Labs9. Office visit10. ED visit11. Hospitalization12. Consults13. Other medications14. Other, specify: ________________15. NoneCodes for Question 12 (Choose all that apply)1. Physician order2. Pharmacy dispensing3. Transcription4. Patient administration5. Monitoring6. Can’t tellCodes for Question 131. No2. YesPage 2 of 2Center of Excellence for Patient Safety Research and Practice 5/27/05Dataform 3: Medication Error and Near Miss Classification Form Version 0.3