APD Area 4 Medication Incident Report

AREA FOUR MEDICATION INCIDENT REPORT

Please Print All Information Clearly and Use One Form for Each Occurrence Report Date: ______

Agency/Provider: ______Group Home Family Home Supported Living Other Date of Med. Error: ______Time: ______Location /Address of Occurrence: Individual Completing This Report: ______Title: Signature: Name of Staff Member Involved: ______Title: Medication Validation: Yes No Person with Disability: ______SSN: Date of Birth:

Name of Medication: ______Dose: ______Times Given: ______Name of Medication: ______Dose: ______Times Given: ______Name of Medication: ______Dose: ______Times Given: ______Type of Medication Error Involved:

Medication Given to the Wrong Person Wrong Medication Given Wrong Dose of Medication Given Medication Not Given Newly Prescribed Order Not Initiated Properly Medication Not Given at the Right Time Medication Refill not Ordered Timely Family Error Shift to Shift Count on Controlled Medication Not Accurate Person Refused Medication Medication Administration Record Not Accurately Documented Other Description of Incident: ______Immediate Action/Intervention: ______Notification: Physician or ARNP Name: ______(Must be notified) Date notified Support Coordinator Name (Must be verbally notified) Date notified Family/Guardian Agency For Persons with Disabilities Abuse Registry Other This Section to be Completed by the Provider Supervisory Personnel Follow-up/Corrective Action taken or Plans: □ Increase Level of Supervision □ Staff Training / Retraining □ Staff Disciplinary Action □ Medication Review □ Medical Consultation / Referral □ Hospitalization □Other

This incident report is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure by Florida Statute. Disclosure of confidential information is prohibited by Federal regulations and (42 CFR Section 480.101) and state law. Revised December 2005 Comments______

Supervisor Name ______Title: ______Signature: ______Contact Phone Number: ______

This incident report is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure by Florida Statute. Disclosure of confidential information is prohibited by Federal regulations and (42 CFR Section 480.101) and state law. Revised December 2005