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Date filled
Event date
Date event was discovered
Who discovered the event?
Pharmacy
Patient’s gender
Patient’s age
Patient’s race
Patient’s ethnicity
Pharmacy contact name
Pharmacy contact email address
Pharmacy contact phone
NCC MERP harm category
Event type (determined by multiple questions)
Were there any contributing communication factors?
Were there any contributing device or supply factors?
Were there any contributing computer system (health information technology) factors?
Were there any contributing human or environmental factors?
Were there any contributing organizational factors?
Were there any contributing patient factors?
Were there any contributing medication event-specific factors?
Were there any contributing policy or procedure factors?
Date event review and analysis completed
Person hours spent in review
Who was notified of this event?
Who else was aware of this event?
Who was given written notification?
Complete account of the event
Cause of the event
Is this a root cause?
Action plan to prevent future event
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