Incident Reporting Form
(Department of Pharmacy Services)
Mukhtar A. Sheikh Hospital

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* 1. Person affected by the incident?

Patient

Visitor

Employee

Student

Others

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* 2. Name:
MRN/Employee#: (responsible person or patient affected)

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* 3. Location?

Inpatient

ER triage

Outpatient

OBGYN

NICU

Pathology

Radiology

Pharmacy

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* 4. Details of the incident

Date of the incident dd/mm/yyyy

Time of incident AM/PM

Day of Incident

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* 5. Description:

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* 6. Incident Type (Non - Pharmacological)

Chemical Spill

Needle prick

Accidental Breakage

Lost

Theft

Manufacturer's Fault

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* 7. Incident Type (Pharmacological)

Nephrotoxicity

Rash

Hepatotoxicity

Renal toxicity

Cardiac Arrhythmias

Thrombocytopenia

Bronchospasm

Extravasation

Hypersensitivity

Cardiac reactions

Others

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* 8. If its a MEDICATION ERROR?

Wrong Drug

Wrong Dose

Wrong Route

Wrong Patient

Time Incorrect

Rate Incorrect

Not Given

Given-Not Prescribed

Order Inaccurate

Not Ordered

Drug Expired

Labelled Incorrectly

Controlled Drug Misuse

Transfusion Reaction

Wrong Prescribing

Wrong dispensing

Wrong administration

Others (if Yes then write description below Q9)

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* 9. Others (Description)

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* 10. "Reporting Person"?

Name

Empoyee #

Designation

Incident Reporting Form(Department of Pharmacy Services)Mukhtar A. Sheikh Hospital

Question Title

* 1. Person affected by the incident?

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* 2. Name:MRN/Employee#: (responsible person or patient affected)

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* 3. Location?

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* 4. Details of the incident

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* 5. Description:

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* 6. Incident Type (Non - Pharmacological)

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* 7. Incident Type (Pharmacological)

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* 8. If its a MEDICATION ERROR?

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* 9. Others (Description)

Question Title

* 10. "Reporting Person"?

Incident Reporting Form
(Department of Pharmacy Services)
Mukhtar A. Sheikh Hospital

* 2. Name:
MRN/Employee#: (responsible person or patient affected)