APD Medication Error Form PDF Details

What is the APD Medication Error Form?

The APD Medication Error Form is a confidential incident-reporting document developed by the Florida Agency for Persons with Disabilities. Providers use it to formally document every medication error in an APD-funded care setting, including the date and time, the location, the medications involved, and the staff member responsible. Completed copies must be stored securely and shared only with authorized supervisory and regulatory personnel per Florida confidentiality rules.

Who must complete this form?

Any APD-licensed provider or direct-support professional who witnesses or becomes aware of a medication error in an APD waiver program is required to file this report. A supervisor must review and sign the corrective-action sections. Relevant parties—including the consumer's physician, family members, and guardians—must be notified as indicated on the form.

What types of medication errors does this form cover?

The form covers administering a drug to the wrong person, wrong medication or dose, wrong time, omitted dose, improper route of administration, and delays in medication refills. Each error type has its own checkbox, allowing supervisors and the APD Department to categorize and track error patterns across care facilities.

Related forms and resources

After completing this report, providers may also need a critical incident report if the error caused harm, or a medication incident report for broader pharmaceutical documentation. For ongoing APD compliance, the APD Support Plan and APD 19 Form are commonly filed alongside this report.

QuestionAnswer
Form NameApd Medication Error Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesagency persons disabilities medication, apd med error report form fillable 2019, agency medication error, apdmyflorida com medication error

Form Preview Example

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:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Immediate Action/Intervention:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Notification:

Physician or ARNP Name: ______________________________________ (Must be notified)

Family/Guardian

Support Coordinator Name: ____________________________________ (Must be notified)

Abuse Registry

Developmental Disabilities Office

Other-List: ____________________________________

____________________________________________________________________________________________________________

This Section to be Completed by Supervisory Personnel

Follow-up/Corrective Action taken or Plans:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Name: _____________________________ Title: ______________________________ Signature: ___________________________

Contact Phone Number: _____________________________________

____________________________________________________________________________________________________________

This Section to be Completed by Department

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

Follow-up Recommended by DD Office:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

How to Edit Apd Medication Error Form Online for Free

You can complete the APD Medication Error Form quickly using FormsPal's free online PDF editor. Follow the steps below to fill in and download your report.

Step 1: Click the "Get Form" button at the top of the page. The form opens in FormsPal's browser-based editor—no software installation required.

Step 2: Fill in the incident details:

  • Date and time – Enter when the medication error occurred.
  • Location – Specify the facility or address where the error took place.
  • Consumer information – Record the full name and identifying details of the individual affected.
  • Medication details – List the medication name, prescribed dose, and administration times.

Step 3: Check the applicable error type (wrong person, wrong dose, wrong time, omitted dose, late refill, or other) in the checkboxes provided on the form.

Step 4: Describe the incident, document all immediate actions taken, and record notifications made to physicians, family, or guardians.

Step 5: Have the supervising staff member complete the corrective-action and follow-up section, then sign and date the form.

Step 6: Click "Done" to finalize. You can download the completed PDF, print it, or send it by email directly from FormsPal.

If the error resulted in physical harm to the consumer, file a critical incident report as well. For general medication documentation, see the Medication Error Form or the Medication Incident Report.

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