General Information

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  Age unit (ASC, Nursing Facility, Pharmacy)
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  Contact email address
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  Contact extension
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  Contact name
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  Contact phone
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  Date discovered
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  Date filled
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  Event date
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  Form ID
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  Last modified date
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  Patient age
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  Patient ethnicity
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  Patient gender (Pharmacy)
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  Patient race
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  Select your pharmacy
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  Submission date
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  Who discovered the event?
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  Who should we contact for clarification or feedback?

Harm Category

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  Did an actual adverse event occur?
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  Did the event contribute to or result in patient death?
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  Did the event reach the patient?
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  Did the event require any of the following significant interventions? (Pharmacy)
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  From the patient’s perspective, how did the event impact them?
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  The Harm Category for this event is
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  Was an intervention necessary to sustain life required?
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  Was extra monitoring or an intervention to preclude harm required?
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  Was the harm permanent?
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  Was the harm temporary?
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  Was the patient harmed?
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  What prevented the event from reaching the patient? (Pharmacy)
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  What was the patient’s response to the event?
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  What was the pharmacy’s response to the event?
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  Which intervention to preclude harm was required? (Pharmacy)

Event Information

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  How preventable was the incident?

Event Type-Specific Questions

Medication or Other Substance Event-Specific Questions

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  Actual directions
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  Actual dosage form
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  Actual dose
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  Actual quantity, amount or size
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  Actual route
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  Actual strength or concentration
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  At what stage in the process did the event originate, regardless of the stage at which it was discovered? (Pharmacy)
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  Brand name
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  Did the patient have an actual or potential allergic or other adverse reaction, including those related to contraindications?
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  Generic name
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  Intended directions
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  Intended dose
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  Intended quantity, amount or size
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  Intended route
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  Intended strength or concentration
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  Medication event factors
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  Medication omitted
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  Patient did not have a prescription
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  Through how many refills was this event carried?
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  Type of medication or other substance event (Pharmacy)
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  Type of other substance (Pharmacy)
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  Type of prescription
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  Was counseling provided during this patient encounter?
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  Was the medication or other substance expired?
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  Was the provided counseling correct?
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  Was the substitution therapeutically equivalent?
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  Was this medication dispensed to the patient?
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  Was this medication or substance intended for another patient?
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  Was this medication or substance used by the patient?
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  Were any of the following INCORRECT?
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  What kind of actual or potential contraindication, allergic reaction, adverse reaction, or drug interaction occurred?
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  What type of medication/substance was involved? (Pharmacy)
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  What type of substitution?
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  What was incorrect on the label?

Contributing Factors

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  Communication factors (Pharmacy)
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  Computer system (health information technology) factors
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  Contributing Factor Category: Communication
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  Contributing Factor Category: Computer Systems (Health Information Technology)
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  Contributing Factor Category: Device, Equipment, or Supply
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  Contributing Factor Category: Human or Environmental
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  Contributing Factor Category: Medication Event Factors
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  Contributing Factor Category: Organizational
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  Contributing Factor Category: Patient (ASC, Hospital, Pharmacy)
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  Contributing Factor Category: Policy or Procedure
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  Device, equipment, or supply factors (Pharmacy)
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  Human or environmental factors (Pharmacy)
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  Medication event factors
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  Organizational factors (Pharmacy)
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  Patient factors (ASC, Hospital, Pharmacy)
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  Please indicate which tasks
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  Policy or procedure factors (Pharmacy)

Review and Analysis Information

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  Date review and analysis completed
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  Person hours spent in review
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  Please specify why no written notification was given
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  Who else was aware of this event?
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  Who was given written notification? (ASC, Hospital, Pharmacy)
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  Who was notified of this event? (Pharmacy)
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  Why was your facility unable to provide written notification?

Summary, Cause and Action Plan Information

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  Action plans
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  Causes
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  Event Summary
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  Is this a root cause?