medsafety form

As you are filling out this form, please be as detailed and objective as possible.

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Pick date
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Type of incident
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Did the incident involve a high risk medication?
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Did the incident involve a chronic medication?
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Did the incident involve a PRN medication?
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Was your instructor or preceptor present at the time the incident occurred?
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Does this error involve a system error?
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Did environmental factors contribute to this incident
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Does the incident include a practice error?
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Which Medication "Right" was involved?
Drug
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Patient
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Were the three patient identifiers followed?
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Dose
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Did this involve a mathematical error?
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Was this a medication wastage error?
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Time
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Was the medication late?
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Was the medication missed?
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Route
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Reason
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Was your medication knowledge prior to administration sufficient?
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Was reason for medication demonstrated to the resident / patient?
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Documentation
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Was the MAR signature completed after administration of medication?
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Was the Narcotic Count record completed appropriately?
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Refuse (related principle)
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Education (related principle)
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Evaluation
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Thank you for submitting the Okanagan College Medication Safety & Learning Form