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:
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Regardless of the severity, every medication incident must be reported to the department supervisor immediately upon discovery.
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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:
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The charge nurse and/or department director/supervisor must document the incident and conduct an immediate investigation.
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Use the specified Medication Incident Report Form for documentation.
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Witnesses, if any, must be documented on the report along with their contact information.
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The Administrator and Director of Nursing Services (DNS) must be informed of all medication incidents and review completed reports.
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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.
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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.
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The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident.
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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.
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Completed Medication Incident Reports and Investigation forms must be submitted within 24 hours to the Administrator and DNS.
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Documentation in the Nurse's Notes is done timely.
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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:
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Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM)
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Requirements of Participation for Nursing Homes, CMS
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Guidelines for Medication Incident Reporting and Investigation, CMS
