Medication Error and Adverse Effect Reporting

This voluntary reporting form for medication errors and adverse events will allow Care Improvement Plus to contribute data to groups such as the US Food and Drug Administration and Institute for Safe Medication Practice for continued review of medication use and safety concerns. This form will also allow us to target specific education to providers and members based on trends in medication errors and adverse events that are noted. Thank you in advance for your participation.

Member Sex:	Male Female
Member Age:	Below 60 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100 And Above
Member ID:

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Reported By:	Member Physician Pharmacist Nurse Caregiver Other	Other:
Contact Phone or Email:		(optional)
Event Date:
Event Time:	Hour Minute Time 1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

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Medication Name:
Medication Dose:
Medication Frequency:
Medication Route:
Medication Dates:	From:
	To:

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Please Select One

Adverse Event Medication Error

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Event Description:
Event Outcomes: (select all that apply)	Death Life Threatening Hospitalization Disability or Permanent Damage Other (specify)

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Did the Error Reach the Member:	Yes No
Error Type:	Medication Dose Frequency Patient Route Other
Error Cause:
Error Effect:
Error Discovery:
Error Location:	Home Hospital Pharmacy Physician's Office Long Term Care Facility

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