Which fields on the form must be filled out in order to submit a pharmacy report?

The form contains required questions that must be completed in order to submit any PSRP report. Depending on the event type selected, there may be additional event-specific questions that must be completed prior to submission. The system will automatically save a partially completed report regardless of whether the required fields are completed..

The following questions are required for any PSRP report:

General Information

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  Contact email address
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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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  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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  Who should we contact for clarification or feedback?

Event Summary, Causes, and Action Plans

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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?

Harm Category

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  Did an actual adverse event occur?
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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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  What was the patient’s response to the event?
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  What was the pharmacy’s response to the event?

Event Details

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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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  Type of prescription
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  Was this medication dispensed to the patient?
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  Were any of the following INCORRECT?

Contributing 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

Event Review and Analysis

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  Date review and analysis completed
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  Person hours spent in review
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  Who else was aware of this event?
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  Who was given written notification? (ASC, Hospital, Pharmacy)