- Email: [email protected]
ISMP Medication Errrors Reporting Program
ISMP Medication Errors Reporting Program ISMP is a federally certified Patient Safety Organization and an FDA MEDWATCH partner Reporters should not provide any individually identifiable health information, including names of practitioners, names of patients, names of healthcare facilities, or dates of birth (age is acceptable).
Date and time of event: Please describe the error. Include description/sequence of events, type of staff involved, and work environment (e.g., code situation, change of shift, no 24-hr. pharmacy, floor stock). If more space is needed, please attach a separate page.
Did the error reach the patient?
Yes
No
Was the incorrect medication, dose, or dosage form administered to or taken by the patient? Circle the appropriate Error Outcome Category (select one—see back for details):
A
B
Yes C
D
E
No F
G
H
I
Describe the direct result of the error on the patient (e.g., death, type of harm, additional patient monitoring). __________________________________ Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar names, distractions). _________________________________ ___________________________________________________________________________________________________________________________ Indicate the location of the error (e.g., hospital, community pharmacy, clinic, nursing home, patient’s home) . ___________________________________ What type of staff or healthcare practitioner made the initial error? ____________________________________________________________________ Indicate if other practitioner(s) were also involved in the error (type of staff perpetuating error). _____________________________________________ What type of staff or healthcare practitioner discovered the error or recognized the potential for error? _______________________________________ How was the error (or potential for error) discovered/intercepted? ___________________________________________________________________ If available, provide patient age, gender, diagnosis. Do not provide any patient identifiers. _________________________________________________ ________________________________________________________________________________________________________________________ Please complete the following for the product(s) involved. (If more space is needed for additional products, please attach a separate page.) Product #1
Product #2
Brand/Product Name (If Applicable)
Generic Name Manufacturer Labeler Dosage Form Strength/Concentration Type and Size of Container Reports are most useful when relevant materials such as product label, copy of prescription/order, etc., can be reviewed. Can these materials be provided?
Yes
No
Please specify: ______________________________________________________________
Suggest any recommendations to prevent recurrence of this error, or describe policies or procedures you instituted or plan to institute to prevent future similar errors. _________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ( Name and Title/Profession Facility/Address and Zip Address/Zip (where correspondence should be sent) Please check the box that applies: Consumer
)
(
Telephone Number
)
Fax Number E-mail
Licensed Healthcare Practitioner
Student/Technician
Copies of reports, without any identifying information, will be sent to third parties such as the manufacturer/labeler and to the Food and Drug Administration (FDA).You have the option of including your name on these copies. ISMP may release my identity to these third parties as follows (check boxes that apply): FDA
The manufacturer and/or labeler as listed above
Anonymous to all third parties
Signature Return to: ISMP, 200 Lakeside Dr., Ste. 200, Horsham, PA 19044 Fax: 215-914-1492 Phone: 800-Fail-Saf(e) (800-324-5723) Submit via the web at: www.ismp.org/merp
Date Date Received by ISMP
File Access Number ©ISMP 2009
100
7/3/09 12:13 PM
NCC MERP Index for Categorizing Medication Errors
NCC MERP Index for Categorizing Medication Errors Algorithm
© 2003 National Coordinating Council for Medication Error Reporting and Prevention
Full-size copies are available: INDEX—www.nccmerp.org/010612_color_index.pdf; ALGORITHM—www.nccmerp.org/010612_color_algo.pdf
Definitions from ISMP and NCC MERP Hazardous Condition (ISMP) A condition or situation that could lead to or cause an error (i.e., Category A).
Monitoring (NCC MERP) To observe or record relevant physiological or psychological signs.
Near Miss (ISMP) A medication error that was detected and corrected before it reached the patient (i.e., Category B).
Intervention (NCC MERP) May include change in therapy or active medical/surgical treatment.
Harm (NCC MERP) Impairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.
Intervention Necessary to Sustain Life (NCC MERP) Includes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.).
Submit a Report to the ISMP Medication Errors Reporting Program (MERP) Mail: ISMP 200 Lakeside Drive Suite 200 Horsham, PA 19044
Internet: www.ismp.org/merp
Phone: 800-Fail-Saf(e) (800-324-5723)
Email: [email protected]
Fax: 215-914-1492
About ISMP
The Institute for Safe Medication Practices (ISMP) is the nation’s only nonprofit, charitable organization devoted entirely to medication error prevention. ISMP provides independent recommendations for the safe use of medications to healthcare professionals, government agencies, accrediting organizations, the pharmaceutical industry and consumers. Its effective error prevention strategies, recognized and respected worldwide, are based on information gained through analysis of reports to a voluntary national program as well as onsite visits to individual healthcare organizations. ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. For more information or to make a donation to support ISMP’s lifesaving work, visit www.ismp.org. A federally certified Patient Safety Organization
101
7/3/09 12:13 PM
Date and time of event: Please describe the error. Include description/sequence of events, type of staff involved, and work environment (e.g., code situation, change of shift, no 24-hr. pharmacy, floor stock). If more space is needed, please attach a separate page.
Did the error reach the patient?
Yes
No
Was the incorrect medication, dose, or dosage form administered to or taken by the patient? Circle the appropriate Error Outcome Category (select one—see back for details):
A
B
Yes C
D
E
No F
G
H
I
Describe the direct result of the error on the patient (e.g., death, type of harm, additional patient monitoring). __________________________________ Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar names, distractions). _________________________________ ___________________________________________________________________________________________________________________________ Indicate the location of the error (e.g., hospital, community pharmacy, clinic, nursing home, patient’s home) . ___________________________________ What type of staff or healthcare practitioner made the initial error? ____________________________________________________________________ Indicate if other practitioner(s) were also involved in the error (type of staff perpetuating error). _____________________________________________ What type of staff or healthcare practitioner discovered the error or recognized the potential for error? _______________________________________ How was the error (or potential for error) discovered/intercepted? ___________________________________________________________________ If available, provide patient age, gender, diagnosis. Do not provide any patient identifiers. _________________________________________________ ________________________________________________________________________________________________________________________ Please complete the following for the product(s) involved. (If more space is needed for additional products, please attach a separate page.) Product #1
Product #2
Brand/Product Name (If Applicable)
Generic Name Manufacturer Labeler Dosage Form Strength/Concentration Type and Size of Container Reports are most useful when relevant materials such as product label, copy of prescription/order, etc., can be reviewed. Can these materials be provided?
Yes
No
Please specify: ______________________________________________________________
Suggest any recommendations to prevent recurrence of this error, or describe policies or procedures you instituted or plan to institute to prevent future similar errors. _________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ ( Name and Title/Profession Facility/Address and Zip Address/Zip (where correspondence should be sent) Please check the box that applies: Consumer
)
(
Telephone Number
)
Fax Number E-mail
Licensed Healthcare Practitioner
Student/Technician
Copies of reports, without any identifying information, will be sent to third parties such as the manufacturer/labeler and to the Food and Drug Administration (FDA).You have the option of including your name on these copies. ISMP may release my identity to these third parties as follows (check boxes that apply): FDA
The manufacturer and/or labeler as listed above
Anonymous to all third parties
Signature Return to: ISMP, 200 Lakeside Dr., Ste. 200, Horsham, PA 19044 Fax: 215-914-1492 Phone: 800-Fail-Saf(e) (800-324-5723) Submit via the web at: www.ismp.org/merp
Date Date Received by ISMP
File Access Number ©ISMP 2009
100
7/3/09 12:13 PM
NCC MERP Index for Categorizing Medication Errors
NCC MERP Index for Categorizing Medication Errors Algorithm
© 2003 National Coordinating Council for Medication Error Reporting and Prevention
Full-size copies are available: INDEX—www.nccmerp.org/010612_color_index.pdf; ALGORITHM—www.nccmerp.org/010612_color_algo.pdf
Definitions from ISMP and NCC MERP Hazardous Condition (ISMP) A condition or situation that could lead to or cause an error (i.e., Category A).
Monitoring (NCC MERP) To observe or record relevant physiological or psychological signs.
Near Miss (ISMP) A medication error that was detected and corrected before it reached the patient (i.e., Category B).
Intervention (NCC MERP) May include change in therapy or active medical/surgical treatment.
Harm (NCC MERP) Impairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.
Intervention Necessary to Sustain Life (NCC MERP) Includes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.).
Submit a Report to the ISMP Medication Errors Reporting Program (MERP) Mail: ISMP 200 Lakeside Drive Suite 200 Horsham, PA 19044
Internet: www.ismp.org/merp
Phone: 800-Fail-Saf(e) (800-324-5723)
Email: [email protected]
Fax: 215-914-1492
About ISMP
The Institute for Safe Medication Practices (ISMP) is the nation’s only nonprofit, charitable organization devoted entirely to medication error prevention. ISMP provides independent recommendations for the safe use of medications to healthcare professionals, government agencies, accrediting organizations, the pharmaceutical industry and consumers. Its effective error prevention strategies, recognized and respected worldwide, are based on information gained through analysis of reports to a voluntary national program as well as onsite visits to individual healthcare organizations. ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. For more information or to make a donation to support ISMP’s lifesaving work, visit www.ismp.org. A federally certified Patient Safety Organization
101
7/3/09 12:13 PM