Medication Error Reporting Form

1. Where did the error happen? *

2. At what point did the error occur? (choose all that apply) *

3. What medication(s) were involved? *

Medication name *

Dosage form

Strength

4. What type of error occurred? *

5. Was the patient harmed because of the error? *

Harm Level

Did not reach the patient ?
Did not reach the patient: Error was caught before reaching the patient
No harm ?
No harm: No symptoms, no treatment needed
Mild harm ?
Mild harm: Mild or temporary symptoms; minor treatment of symptoms needed
Moderate harm ?
Moderate harm: Symptoms required new or additional treatment; if already hospitalized, the stay was extended
Severe harm ?
Severe harm: Major treatment needed to save the patient's life; shortened life expectancy, caused major long-term harm
Death ?
Death: Error contributed to death of the patient

6. Tell us what happened in your own words.

Do not include identifying information such as health card numbers, addresses, or names of individuals, health care providers, pharmacies, or organizations. If you have suggestions to prevent the error from happening again, please include them here.

7. What steps were taken because of the error? (choose all that apply)

8. What was the age of the person affected by the error?

9. Who discovered the error?

10. Date the error occurred

Month: Year:

11. Province / Territory

12. Do you give permission for ISMP Canada to contact you to learn more about the error?

Contact Permission

Providing contact information allows ISMP Canada to contact you if we need more information to help us learn from your report. ISMP Canada will only contact you for the purpose of follow up, for example, if we need clarification about your description of the incident. After the incident report is reviewed and analyzed, ISMP Canada will not keep information that could identify individuals who agreed to be contacted.

Contact Permission

Yes – I give permission

No – Do not contact me

Before submitting your report, please review and accept our terms.

This website does not provide medical advice. If you require medical advice, contact your healthcare provider or, if you think you may have a medical emergency, call 911.

Before submitting your report, it is important that you read, understand and accept the following:

1. The Institute for Safe Medication Practices Canada (ISMP Canada) cannot investigate complaints about individual cases with the healthcare organization or professional that provided your care. Information on what to do to resolve a concern about the safety of your care is available on the website of the Canadian Patient Safety Institute under "Patient Concern Resolution Process".

2. ISMP Canada does not need to collect information that identifies a patient or that could be combined with other information to identify a patient. We cannot accept a report that includes a name, address, telephone number, fax, email address, health care number, or any other information that could identify an individual patient. If you are reporting an incident that happened to someone else, please do not use terms that might identify an individual or your relationship with an individual (for example "he/she", "son/daughter", "husband/wife", "mother/father").

3. Please do not include the name(s) of health professionals or healthcare organizations in your report.

4. You will be invited to provide your contact information at the end of the reporting process, for follow-up purposes. Providing contact information is optional. By providing your contact information, you are consenting to be contacted by ISMP Canada. After the incident report is fully reviewed and analyzed, ISMP Canada will not keep information that could identify individuals who agreed to be contacted.

5. By submitting your report, you are giving ISMP Canada your permission to use the information you provide in order to learn about safe medication use. ISMP Canada will be free to reproduce, use, and distribute such information to others for the purpose of recommending safe medication practices and alerting others to prevent harmful incidents, but ISMP Canada will protect your privacy. For details on how we will protect your privacy, click here.

I have read, understood and accept these terms. *