Mediation Error Report
Date of Report: ______________________________
Name of person completing this report: _______________________________________
Signature of person completing this report:_____________________________________
Child’s Name: _____________________________________________________________
Date of Birth:__________________________________
Date error occurred: ____________________________ Time Noted:____________
Person administering Medication: _____________________________________________
Prescribing Health Care Provider: _____________________________________________
Name of Medication: _______________________________________________________
Dose: ___________________________ Scheduled Time:____________________
Describe the error and how it occurred: __________________________________________________________________________
Action Taken/intervention: _________________________________________________
Nurse Consultant notified: Yes____ No_____ Date: _______________ Time:________
Parent/Guardian notified: Yes____ No___ Date:____________ Time:_______________
Name of the parent/guardian that was notified: ________________________________
Other persons notified: _____________________________________________________
Follow-up and Outcome: ____________________________________________________
__________________________________________________________________________
Owner’s Signature: __________________________________________
Parent’s Signature: ________________________________________________