This page provides a list of all questions found on the PSRP reporting form for pharmacies. They are grouped alphabetically by the section of the form in which they appear. This list does not indicate which questions are required for all pharmacy reports nor which questions only appear for certain event types. A list of required questions can be found here: Required Fields for Pharmacies.

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?