Report on Medication Incidents

Report on Medication Incidents 

Standard 
All medication incidents occurring on the facility’s premises must be reported, documented, and investigated. This ensures compliance with CMS Requirements of Participation and the State Operations Manual (SOM) guidelines for long-term care facilities (LTC). 

Policy 
To ensure the safety and well-being of residents by promptly addressing and documenting all medication incidents, and implementing measures to prevent recurrence. 

Practice Guidelines 

Reporting of Medication Incidents: 

• Regardless of the severity, every medication incident must be reported to the department supervisor immediately upon discovery. 

• Complete the Medication Incident Report Form on the shift that the incident occurred. 

Medication Incident Report Form 

INCIDENT NUMBER: ______________________ 
CLASSIFICATION: _____________________________ 

RESIDENT: ___________________________ 
RM#: ____________________ 
DATE: _________________ 

ORDER AS WRITTEN: _______________________________________________________________ 

ORDER AS TRANSCRIBED: ___________________________________________________________ 

ORDER AS ADMINISTERED/OMITTED: ________________________________________________ 

Specific Description of Incident: ______________________________________________________ 

How many times was the medication erroneously given or omitted? ___________________________ 

How was the error discovered? ________________________________________________________ 

Was MD notified? ______________________ 
Time: _______________ 
Date: _______________ 

Action taken by MD: _______________________________________________________________ 

Was family notified? ___________________ 
Time: _______________ 
Date: _______________ 

Were any ill effects noted or observed? _________________________________________________ 

Is the patient aware of the error? ________ 

Specifically state how the error could have been avoided: __________________________________ 

COMMENTS: _____________________________________________________________________ 

Signature of Nurse/Pharmacist Responsible for Error 

Signature of Medical Director 

Signature of Nurse/Pharmacist Discovering Error 

Signature of Director of Nursing Services (DNS) 

Documentation and Investigation Action: 

• The charge nurse and/or department director/supervisor must document the incident and conduct an immediate investigation. 

• Use the specified Medication Incident Report Form for documentation. 

• Witnesses, if any, must be documented on the report along with their contact information. 

• The Administrator and Director of Nursing Services (DNS) must be informed of all medication incidents and review completed reports. 

• If the incident is of a serious nature, it shall be reported by telephone regardless of the time or day. Follow the policy/procedure for Reporting to Government Agencies and Investigation of Abuse Practice Guidelines. 

• The Administrator must notify the Director of Clinical Services and Director of Operations immediately, regardless of the time of day, if the medication incident is of a serious nature. 

• The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident. 

• The Administrator is responsible for coordinating the investigation and assuring appropriate action is taken, including conducting interviews and collecting written statements from all staff involved. 

• Completed Medication Incident Reports and Investigation forms must be submitted within 24 hours to the Administrator and DNS. 

• Documentation in the Nurse's Notes is done timely. 

• The resident is monitored for 72 hours post-incident with Nurse's Notes every shift, including vital signs and documentation of any ill effects. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• Guidelines for Medication Incident Reporting and Investigation, CMS