Report a medication event clearly and securely.

Submit the event directly to a separate, restricted clinical review team. This workflow is independent from case-review intake.

Encrypted at restMedication-review access onlyNo public report access

Protected medication-safety informationDo not include patient names in this form. The report is encrypted and routed only to authorized medication-error reviewers.

Website

Basic Information

Identify the facility and event dates.

Facility *Date of EventDate Report Completed

Event Information

Complete all five steps. Wording matches the approved medication-error form.

STEP 1 – WHAT HAPPENED? (Check all that apply) *

Medication given at wrong timeMedication not givenWrong patientWrong medicationWrong doseWrong routeMedication given without an active orderMedication dropped, lost, or damagedDocumentation errorMAR ErrorOther

STEP 2 – OUTCOME *

Near miss – did not reach the patientReached patient, no harm notedReached patient, monitoring, or intervention requiredSerious harm or emergency responseOutcome unknown at time of reportDose was missed

STEP 3 – MEDICATION CLASSIFICATION (Check all that apply) *

CARDIOVASCULARINSULINMENTAL HEALTHORAL DIABETICPAIN MANAGEMENTWITHDRAWAL MEDICATIONMATANTIMICROBIALSEIZURE MEDICATIONMISCELLANEOUSHYPERTENSION

STEP 4 – IMMEDIATE ACTIONS TAKEN *

Practitioner notifiedMonitoring initiatedSENT TO OUTSIDE FACILITY/ EROther

STEP 5 – CONTRIBUTING FACTORS & CONTEXT (Check all that apply) *

Patient movementTiming/scheduling conflictStaffing or coverage issueCommunication gapOrder clarification neededEnvironment/security constraintTraining or orientation issueMedication availability/pharmacy delayPharmacy ErrorProcess not followedOther

Ready to submit?The restricted review team receives a content-free notification.

Sentinel Patient Safety OrganizationSecure intake · Restricted processing · No public report access