Medication Error Incident Report Form for Child Care

Submit this form by mail, email, or fax to the appropriate regulatory body. Ensure all required information is accurately entered, and all necessary parties are notified. For emailed submissions, attach the completed form and send it to the provided email address. For faxed submissions, ensure the form is clearly legible. Verify that all signatures are included before sending. Direct any questions to the Office of Child Care via their contact number.

The Medication Error Incident Report Form should be updated and submitted as soon as an incident occurs. Regular reviews of the form should be scheduled to ensure all information remains accurate and up to date.

The purpose of the Medication Error Incident Report Form is to document any medication errors that occur within a child care facility. This form ensures that all incidents are properly recorded, reviewed, and acted upon to maintain the safety and well-being of the children in care. It also facilitates transparency between child care providers, health care professionals, and parents/guardians, ensuring that everyone is informed and can take appropriate actions.

• 1. Facility/Provider Name: The name of the child care facility or provider reporting the incident.
• 2. Address: The address of the reporting child care facility.
• 3. Child's Name: The name of the child involved in the medication error incident.
• 4. Date of Birth: The date of birth of the child involved in the incident.
• 5. Date Incident Occurred: The date when the medication error incident took place.
• 6. Date: The current date when the form is being filled out.
• 7. Phone: The contact phone number of the child care facility or provider.
• 8. Time Noted: The time when the medication error was noted.
• 9. Person Administering Medication: The name of the person who administered the medication.
• 10. Name of the Medication & Strength: The name and strength of the medication involved in the incident.
• 11. Expiration Date: The expiration date of the medication involved.
• 12. Dose: The dose of the medication that was administered.
• 13. Scheduled Time: The scheduled time for the medication administration.
• 14. Route of Administration: The route through which the medication was administered.
• 15. Purpose: The purpose of the medication being given.
• 16. Describe the Incident and How it Occurred: A detailed description of the incident and how it occurred.
• 17. General condition of the child: The overall condition of the child following the incident.
• 18. Follow up in 24 hours: Details on the follow-up action taken within 24 hours of the incident.
• 19. Signature, Position and Date of the Person Completing Form: The signature of the person completing the form, along with their position and the date.
• 20. Prescribing Health Care Provider: Details of the health care provider who prescribed the medication.
• 21. Medication Administration Error: Check boxes to indicate the type of medication error (e.g., Wrong Child, Wrong Medicine, etc.).
• 22. Action Taken: A description of the actions taken in response to the medication error.
• 23. Name of Parent/Guardian Notified: The name of the parent or guardian who was notified about the incident.
• 24. Date: The date when the parent/guardian was notified.
• 25. Time: The time when the parent/guardian was notified.
• 26. Poison Control Notified: Indicates whether Poison Control was notified and their response.
• 27. 911 Called: Indicates whether 911 was called in response to the incident.
• 28. Director/Provider Notified: Indicates whether the director/provider was notified about the medication error incident.
• 29. OCC Licensing Staff notified: Details on whether OCC Licensing Staff were notified.
• 30. OCC Nurse Consultant Notified: Details on whether the OCC Nurse Consultant was notified.
• 31. Corrective Action Plan and Completed Date: Details of the corrective action plan and the date it was completed.
• 32. Director/Provider Signature & Date: The signature and date of the director or provider, if applicable.

Failing to submit this form can lead to serious consequences, including non-compliance with state regulations and compromised child safety.

• Regulatory Non-Compliance: Not submitting the form can result in penalties or legal action for failing to adhere to state regulations.
• Child Safety: Failing to document and act on medication errors can put children at risk and delay necessary medical interventions.

• 1. Medication Error Documentation: Record any instance where a medication error occurs, detailing the incident and response.
• 2. Regulatory Compliance: Submit the form to comply with state regulations regarding child care and medication safety.
• 3. Informing Guardians: Use the form to notify and inform parents or guardians about the incident and actions taken.