BPF/104/ME/02
MEDICATION ERROR (ME) REPORT FORM For PSD, MOH use
Reporters do not necessarily have to provide any individual identifiable health information, including names of practitioners,
names of patients, names of healthcare facilities, or dates of birth (age is acceptable)
1 Date of event: dd/mm/yy 2 Time of event: hh/mm (24 hr)
3 Type of Facility: *MOH/ Other Government Facility 4 Location Ward (Please specify: Medical/Pead/Ortho/ ........................................... )
of event: Clinic (Please specify: Outpatient/Specialist/Dental/ .............................. )
Hospital Clinic Pharmacy Pharmacy (Please specify: Inpatient/Outpatient/Satellite/A&E/ .............. )
A&E
Others:
Others (Please specify .......................................................................... )
5 Please describe the error. Include description/ sequence of events and work environment (e.g. change of shift, short staffing, during peak hours).
If more space is needed, please attach a separate page.
6 In which process did the error occur? 7 Did the error reach the patient? 9 Describe the direct result on the patient
Prescribing YES NO (e.g. death, type of harm, additional patient
Dispensing (includes filling) monitoring e.g. BP, HR, glucose level etc.).
8 Was the incorrect medication, dose or dosage
Administration form administered to or taken by the patient?
Others (Please specify) :
YES NO
_
10 Please tick the appropriate Error Outcome Category (Select one)
ERROR, HARM
NO ERROR
Potential error, circumstances/ events have E Treatment/ intervention required - caused temporary harm F
A
potential to cause incident Initial/ prolonged hospitalization - caused temporary harm G
ERROR, NO HARM Caused permanent harm
B Actual Error - did not reach patient H Near death event
C Actual Error - caused no harm ERROR, DEATH
D Additional monitoring required - caused no harm I Death ** © 2001 NCCMERP.
11 Indicate the possible error cause(s) and contributing factor(s)
Staff factors Task and technology Work and environment
Inexperienced personnel Failure to adhere to work procedure Heavy workload
Inadequate knowledge Use of abbreviations Peak hour
Distraction Illegible prescriptions Stock arrangements/ storage problem
Medication related Patient information/ record unavailable/ inaccurate Others (please specify):
Sound alike medication Wrong labeling/ instruction on dispensing envelope ………………………………………………...
Look alike medication or bottle/ container
Look alike packaging Incorrect computer entry ...............................................................….
For question 12-14, please fill each box with one of the following option.
a. Specialist f. Nurse k. Pharmacist Assistant (Trainee)
b. Medical Officer (MO) g. Nurse (Trainee) l. Patient/ Caregiver
c. Houseman Medical Officer (HMO) h. Assistant Medical Officer (AMO) m. Dentist
d. Pharmacist i. Assistant Medical Officer (AMO Trainee) n. Others (Please specify in the box)
e. Provisional Registered Pharmacist (PRP) j. Pharmacist Assistant
12 Which category made the initial error? (If “n. others”, please specify ................................................... )
13 Other category also involved in the error? (If “n. others”, please specify ................................................... )
14 Which category discovered the error or recognised the potential error? (If “n. others”, please specify................................................... )
15 If available, please provide patient's particulars (Do not provide any patient identifiers).
Age: *years/ months/ days Gender: Male Female Diagnosis: _
16 Product Details: Please complete the following for the product(s) involved. Kindly attach a separate page for additional products.
Product Description Product # 1 (intended) Product # 1(error)
16.1 Generic Name (Active Ingredient)
16.2 Brand / Product Name
16.3 Dosage Form
16.4 Dose, frequency, duration, route
Please fill in 16.5-16.7 if error involved similar product packaging:
Product Description Product # 1 (intended) Product # 1(error)
16.5 Manufacturer
16.6 Strength / Concentration
16.7 Type and Size of Container
* Please delete where not applicable
18 Suggest any recommendations, or describe policies or procedures you
17 Reports are most useful when relevant materials such as
instituted or plan to institute to prevent future similar errors. If available,
product label, copy of prescription/order, etc., can be
kindly attach investigational report e.g. Root Cause Analysis (RCA).
reviewed. Can these materials be provided?
No
Yes, Please specify
Reporter’s Details
Name : For official use :
Profession : Date report received :
Facility and Address : dd/mm/yy
Postcode : ME Type
E-mail :
ME Category
Telephone number : Fax Number :
(Fold here)
Medication Safety
Is Everyone’s Responsibility
www.pharmacy.gov.my
E-mail: [email protected]
(Fold here)
NO STAMP REQUIRED
SETEM POS TIDAK DIPERLUKAN
REPLY PAID / JAWAPAN BERBAYAR
MALAYSIA
No. Lesen : BRS 0915 SEL
Medication Safety Centre (MedSC),
Pharmaceutical Services Division,
Ministry Of Health Malaysia,
P.O. Box 924, Jalan Sultan,
46790 Petaling Jaya, Selangor.
