...
The form contains required questions that must be completed in order to submit any report. Depending on the event type selected, there may be additional event-specific questions that must be completed prior to submission (see Which events trigger additional event-specific questions?). If needed, you will be able to . The system will automatically save a partially completed form report regardless of whether the required fields are completed..
The following questions are required for any adverse event report:
...
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?
...
General Information
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Event Summary, Causes, and Action Plans
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Harm Category
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Event Details
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Contributing Factors
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
Event Review and Analysis
| Filter by label (Content by label) | ||||||||
|---|---|---|---|---|---|---|---|---|
|
| Page Properties | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||
|
...
|
...
|