Example HACC Service
MEDICATION INCIDENT REPORT
SUPPORT WORKER/COORDINATOR TO COMPLETE – INCIDENT DETAILS
Date:..................................................... Time:
CLIENT’S NAME:
Report completed by:
Describe medication incident:
Possible reason(s) for incident:
Immediate action taken:
Coordinator notified: Yes No Date/Time:
Doctor notified: Yes No Date/Time:
Pharmacist notified: Yes No Date/Time:
Next of Kin notified: Yes No Date/Time:
Treatment ordered by Doctor/Pharmacist:
SUPPORT WORKER/COORDINATOR TO COMPLETE - INCIDENT ANALYSIS
Category of Incident:
Incorrect client Request by a client/carer to not give medication
Incorrect medicine Breach of the Organisation policy and guidelines
Incorrect dose Client refuses medication
Incorrect time Incorrect storage of medications
Incorrect route Incorrect supply of medications from the pharmacy
Split or dropped medicine Other (describe)
Out of date medicine
Missing medicine
Lack of documentation such as
assessment, medication order,
medication support plan, medication
record sheet (if required)
Page 1 of 2
Medication Incident Report
Page 2 of 2
COORDINATOR TO COMPLETE - INCIDENT ANALYSIS CONCLUSIONS
What, if anything could have prevented the incident?
Describe:
Was the incident related to a procedure breakdown (staff focus)? Yes No
Comment:
Was the incident related to the medication management system
(prescription, supply, documentation focus)? Yes No
Comment:
Was the immediate action taken appropriate? Yes No
Comment:
COORDINATOR TO COMPLETE - ACTION PLAN Date
Who By When
(Insert further actions as required) Completed
Analysis completed
Follow up with staff member/s
COORDINATOR TO COMPLETE - CLOSURE
Evaluation (If appropriate, describe how action/improvements were evaluated and the result):
Outcome or end result: (Tick applicable boxes)
Issue resolved - no improvements implemented
Improvement implemented (describe)
CLOSED OUT/COMPLETE:
Coordinator’s Signature:................................................................. Date:
Reviewed September 2016
