5141.21 Form #3

   MEDICATION ERROR OR INCIDENT REPORT

Date or Report:________________________ School: _______________________________ Prepared by: _________________________

Name of Student:  ___________________________________________________________ Grade: ______________________________

Home Address: _____________________________________________________________ Phone: ______________________________

Date error occurred: _________________________________________________________ Time noted: __________________________

Person Administering Medication: ___________________________________________________________________________________

Authorized Prescriber: ____________________________________________________________________________________________

Reason medication was prescribed: __________________________________________________________________________________

Date of Order: ________________________Instructions for Administration: __________________________________________________

Describe the error and how it occurred (use reverse side if necessary)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Action Taken: (by school nurse)

Prescribing practitioner notified:                 [ ] Yes    [ ]  No    Date ___________________Time _________________

School Medical Advisor notified:               [ ] Yes    [ ]  No    Date ___________________Time _________________

School Principal notified:                           [ ]  Yes   [ ]  No    Date ___________________Time _________________

Superintendent of Schools
notified (by Principal):                               [ ] Yes    [ ]  No    Date ___________________Time _________________

Parent/Guardian notified:                           [ ] Yes    [ ]  No    Date ___________________Time _________________

Outcome: ___________________________________________________________________________________________________

___________________________________________________________________________________________________________

Name:  _____________________________________________________________________________________________________
            Print or Type                                                                     Signature                                  Title                                         Date

Note:  Any error in the administration of medication shall be documented in the student's cumulative health record, or for before- and after-school programs and school readiness programs in the child's program record.