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Incident Reporting Form
(Department of Pharmacy Services)
Mukhtar A. Sheikh Hospital
1.
Person affected by the incident?
Patient
Visitor
Employee
Student
Others
2.
Name:
MRN/Employee#: (responsible person or patient affected)
3.
Location?
Inpatient
ER triage
Outpatient
OBGYN
NICU
Pathology
Radiology
Pharmacy
OR
4.
Details of the incident
Date of the incident dd/mm/yyyy
Time of incident AM/PM
Day of Incident
5.
Description:
6.
Incident Type (Non - Pharmacological)
Chemical Spill
Needle prick
Accidental Breakage
Lost
Theft
Manufacturer's Fault
7.
Incident Type (Pharmacological)
Nephrotoxicity
Rash
Hepatotoxicity
Renal toxicity
Cardiac Arrhythmias
Thrombocytopenia
Bronchospasm
Extravasation
Hypersensitivity
Cardiac reactions
Others
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)
9.
Others (Description)
10.
"Reporting Person"?
Name
Empoyee #
Designation
Current Progress,
0 of 10 answered