• linkId: Medication/header

Form ID:*

• Flags:
• linkId: 0

Event ID:*

• linkId: 74080-3/74081-1

Initial Report Date (HERF Q1)*

• linkId: 74080-3/30947-6

Medication or Other Substance

• linkId: Medication/SEC00

Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply including Health Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF).

• linkId: Medication/SEC00.0

*

• linkId: Medication/SEC01/74080-3

1.: What type of medication/substance was involved?*MedicationsBiological productsNutritional productsExpressed human breast milkMedical gases (e.g., oxygen, nitrogen, nitrous oxide)Contrast mediaRadiopharmaceuticalsPatient food (not suspected in drug-food interactions)Drug-drug, drug-food, or adverse drug reaction as a result of a prescription and/or administration of a drug and/or food prior to admissionOther substance: PLEASE SPECIFY

• linkId: 74080-3/74076-1
• Answers: AHRQ_Medication_Q1

2.: What type of medication?*Prescription or over-the-counter (including herbal supplements)Compounded preparationsInvestigational drugsUnknown

• linkId: 74080-3/74075-3
• Enable When: todo
• Answers: AHRQ_Medication_Q2

3.: Please list all ingredients:*

• linkId: 74080-3/74077-9-q
• Enable When: todo

4.: What type of biological product?VaccinesOther biological products (e.g., thrombolytic)

• linkId: 74080-3/74074-6
• Enable When: todo
• Answers: AHRQ_Medication_Q4

5.: What was the lot number of the vaccine?*

• linkId: 74080-3/30959-1
• Enable When: todo

6.: What type of nutritional product?*Dietary supplements (other than vitamins or minerals)Vitamins or mineralsEnteral nutritional products, including infant formulaParenteral nutritional productsOther: PLEASE SPECIFY

• linkId: 74080-3/74073-8
• Enable When: todo
• Answers: AHRQ_Medication_Q6

*

• linkId: 74080-3/74073-8/Other/Specify
• Enable When: todo

*

• linkId: 74080-3/74076-1/Other/Specify
• Enable When: todo

7.: Which of the following best characterizes the event?*Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)Unsafe conditionAdverse reaction in patient to the administered substance without any apparent incorrect actionUnknown

• linkId: 74080-3/74072-0
• Enable When: todo
• Answers: AHRQ_Medication_Q7

8.: What was the incorrect action?Incorrect patientIncorrect medication/substanceIncorrect dose(s)Incorrect route of administrationIncorrect timingIncorrect rateIncorrect duration of administration or course of therapyIncorrect dosage form (e.g., sustained release instead of immediate release)Incorrect strength or concentrationIncorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.Expired or deteriorated medication/substanceMedication/substance that is known to be an allergen to the patientMedication/substance that is known to be contraindicated for the patientIncorrect patient/family action (e.g., self-administration error)Other: PLEASE SPECIFY

• linkId: 74080-3/74071-2
• Enable When: todo
• Answers: AHRQ_Medication_Q8

9.: Which best describes the incorrect dose(s)?*OverdoseUnderdoseMissed or omitted doseExtra doseUnknown

• linkId: 74080-3/74070-4
• Enable When: todo
• Answers: AHRQ_Medication_Q9

10.: Which best describes the incorrect timing?*Too earlyToo lateUnknown

• linkId: Medication/74069-6
• Enable When: todo
• Answers: AHRQ_Medication_Q10

11.: Which best describes the incorrect rate?*Too quicklyToo slowlyUnknown

• linkId: 74080-3/74068-8
• Enable When: todo
• Answers: AHRQ_Medication_Q11

12.: Which best describes the incorrect strength or concentration?*Too highToo lowUnknown

• linkId: Medication/74067-0
• Enable When: todo
• Answers: AHRQ_Medication_Q12

13.: What was the expiration date?*

• linkId: Medication/74066-2
• Enable When: todo

14.: Was there a documented history of allergies or sensitivities to the medication/substance administered?*YesNoUnknown

• linkId: Medication/74065-4
• Enable When: todo
• Answers: AHRQ_Y/N/UNK

15.: What was the contraindication (potential or actual interaction)?*Drug-drugDrug-foodDrug-diseaseOther: PLEASE SPECIFY

• linkId: Medication/74064-7
• Enable When: todo
• Answers: AHRQ_Medication_Q15

*

• linkId: Medication/74064-7/Other/Specify
• Enable When: todo

*

• linkId: 74080-3/74071-2/Other/Specify
• Enable When: todo

16.: At what stage in the process did the event originate, regardless of the stage at which it was discovered?*PurchasingStoringPrescribing/orderingTranscribingPreparingDispensingAdministeringMonitoringUnknownOther: PLEASE SPECIFY

• linkId: 74080-3/74063-9
• Enable When: todo
• Answers: AHRQ_Medication_Q16

*

• linkId: 74080-3/74063-9/Other/Specify
• Enable When: todo

Please provide the following medication details for any medications or other substances directly involved in the event.

• linkId: 74080-3/74078-7.0

For an near miss, omit question 27

• linkId: 74080-3/74078-x
• Enable When: todo

*

• linkId: 74080-3/74078-7
• Enable When: todo

17.: Generic name or investigational drug name

• linkId: 74080-3/74078-7/74062-1

18.: Ingredient RXCUI (if known)

• linkId: 74080-3/74078-7/74061-3

19.: Brand name (if known)

• linkId: 74080-3/74078-7/74060-5

20.: Brand name RXCUI (if known)

• linkId: 74080-3/74078-7/74059-7

21.: Manufacturer (if known)

• linkId: 74080-3/74078-7/74058-9

22.: Strength or concentration of product

• linkId: 74080-3/74078-7/74057-1

23.: Clinical drug component RXCUI (if known)

• linkId: 74080-3/74078-7/74056-3

24.: Dosage form of Product

• linkId: 74080-3/74078-7/74055-5

25.: Dose form RXCUI (if known)

• linkId: 74080-3/74078-7/74054-8

26.: Was this medication/substance prescribed for this patient?*YesNo

• linkId: 74080-3/74078-7/74053-0
• Enable When: todo
• Answers: AHRQ_Y/N

27.: Was this medication/substance given to this patient?*YesNo

• linkId: Medication/74052-2
• Enable When: todo
• Answers: AHRQ_Y/N

• linkId: Medication/SEC03
• Enable When: todo

28.: What was the intended route of administration?*Cutaneous, topical application, including ointment, spray, patchSubcutaneousOphthalmicOral, including sublingual or buccalOticNasalInhalationIntravenousIntramuscularIntrathecalEpiduralGastricRectalVaginalUnknownOther: PLEASE SPECIFY

• linkId: 74080-3/74051-4
• Answers: AHRQ_Medication_Q28_Q29

*

• linkId: 74080-3/74051-4/Other/Specify
• Enable When: todo

29.: What was the actual route of administration (attempted or completed)?*Cutaneous, topical application, including ointment, spray, patchSubcutaneousOphthalmicOral, including sublingual or buccalOticNasalInhalationIntravenousIntramuscularIntrathecalEpiduralGastricRectalVaginalUnknownOther: PLEASE SPECIFY

• linkId: 74080-3/74050-6
• Answers: AHRQ_Medication_Q28_Q29

*

• linkId: 74080-3/74050-6/Other/Specify
• Enable When: todo

Thank you for completing these questions.

• linkId: Medication/SEC04

OMB No. 0935-0143 Exp. Date 10/31/2014 Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

• linkId: Medication/SEC04.0

Reporting information

• Flags:
• linkId: Reporting

Reported by:

• linkId: Reporting/who

Reported date:

• linkId: Reporting/when

• linkId: Medication/footer

AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance

• linkId: Medication/footer.0