Individual Practitioner Reporting Program

1*
Incident

3*
Medication(s)

6*
Reporter

7
Contributing Factors

*Indicates Required Fields (Total of nine required fields.)

Report a med error fr

Individual Practitioner Reporting

Medication Incidents Including Near Misses

Reporting by individual practitioners is an important component in identifying early opportunities for enhancing medication safety. ISMP Canada sincerely appreciates your willingness to share information about medication incidents and related findings. Please include as much information about the incident as possible. INFORMATION SUBMITTED WILL BE KEPT STRICTLY CONFIDENTIAL AND PROTECTED. Please do not supply identifying information (e.g., patient name or date of birth, hospital name, or healthcare provider names).

1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
0
1

Date of Incident:

Time of Incident:

Incident Description / How Discovered:*

Stages Involved:*

Prescribing	Order Entry/Transcription
Dispensing/Delivery	Administration
Monitoring	Other

Type of Incident:*

Discovered By:*

Care Area Type:*

Severity / Outcome:*

	NO ERROR - Circumstances or events that have the capacity to cause harm
	NO HARM - An incident occurred but the incident did not reach the patient (An "error of omission" does reach the patient)
	NO HARM - An incident occurred that did reach the patient, but did not cause patient harm
	NO HARM - An incident occurred that reached the patient and monitoring was required to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm
	HARM - An incident occurred that may have contributed to or resulted in temporary harm to the patient and required intervention
	HARM - An incident occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization
	HARM - An incident occurred that may have contributed to or resulted in permanent patient harm
	HARM - An incident occurred that required intervention necessary to sustain life
	DEATH - An incident occurred that may have contributed to or resulted in the patient's death

Intervention:

	Medication 1	Medication 2
Medication Name:*
Strength:
Route of Administration:
Manufacturer:
Lot Number:
Confusing drug name, label or packaging:* Yes No
Upload Picture or PDF File:	(Maximum 3 files of 5 000 000 bytes each)

Action:
Comments/ Recommendations:
System Improvement Strategies Implemented:

Non-identifying Patient Information:

Non-Patient Specific:

Age Category:

Gender:

Male

Female

Unknown

I may be contacted by ISMP Canada for follow-up about this medication incident:* Yes No If yes, please provide contact information:
Name:
Practice Setting:
City:
Province:
Postal Code:
email:
Phone:

Select Key Medication Use System Element from each button on the left, then select contributing factor(s) from the window to the right.

Critical patient information missing

Critical drug information missing

Miscommunication of drug order

Drug name, label, packaging problem

Drug storage or delivery problem

Drug delivery device problem

Environmental, staffing, or workflow problem

Lack of staff education

Patient education problem

Lack of quality control or independent check systems

Hold down the control key 'Ctrl' to select more than one item, or to remove all choices.

Individual practitioner reports of medication incidents contribute to the Canadian Medication Incident Reporting and Prevention System (CMIRPS). Through CMIRPS, some of Canada's most highly regarded organizations committed to patient safety are working together to support your efforts to enhance the safety of the medication system. The collaborating parties of the CMIRPS program are: Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI). More information about ISMP Canada's activities for CMIRPS.