Apd Medication Error Form – Fill Out and Use This PDF

Agency for Persons with Disabilities

MEDICATION ERROR REPORT

THIS DOCUMENT IS SUBJECT TO CONFIDENTIALITY REQUIREMENTS AND SHOULD BE HANDLED ACCORDINGLY

Please Print All Information Clearly and Use One Form For Each Occurrence		Report Date (mm/dd/yy): ____________
Agency/Provider: _____________________________________	Group Home	Family Home	Supported Living	Other
Address: ____________________________________________	City: __________________________		State: ___ Zip: _______

Date of Med. Error (mm/dd/yy): ________ Time: ___________ Location of Occurrence: ___________________________________

Individual Completing This Report: _________________________	Title: _________________ Signature: ____________________
Name of Staff Member Involved: ___________________________	Title: _______________ Medication Certified? Yes	No

Consumer: __________________________________________ SSN: _________________ Date of Birth (mm/dd/yy): __________

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 within 24 hours	Medication Not Given at the Right Time
Medication Refill Not Ordered Timely (no doses missed)	Family Error
Shift to Shift Count on Controlled Medication Not Accurate	Client Refused Medication
Medication Administration Record Not Accurately Documented

Other __________________________________________________________________________________________________

Description of Incident and Required Medical Nursing Care:

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Immediate Action/Intervention:

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Notification:

Physician or ARNP Name: ______________________________________ (Must be notified)

Family/Guardian	Support Coordinator Name: ____________________________________ (Must be notified)
Abuse Registry	Developmental Disabilities Office	Other-List: ____________________________________

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This Section to be Completed by Supervisory Personnel

Follow-up/Corrective Action taken or Plans:

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Name: _____________________________ Title: ______________________________ Signature: ___________________________

Contact Phone Number: _____________________________________

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This Section to be Completed by Department

Date Report was received by DD Office (mm/dd/yy): _____________________

Follow-up Recommended by DD Office:

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APD Form 65G7-05, adopted 3/10/08 by Rule 65G-7.006(2)(d), F.A.C.