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Run: Medication Error and Incident Report Form (School Health Office)

A school health office form for documenting medication administration errors, near misses, and follow-up in one place. It captures what happened, who was not...

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Report Overview

Date of report (required)

Time of report (required)

Reported by (required)

Reporter role (required)

Incident type (required)

Was a student affected? (required)

Brief incident summary (required)

Describe what happened in plain language. Do not include unnecessary PII.

Student and Medication Details

Student name (required)

Student ID

Optional if your school uses a student ID for record matching.

Grade level

Medication name (required)

Medication form

Prescribed dose

Enter the ordered dose as written on the authorization or medication label.

Scheduled administration time

Deviation From Medication Rights

Type of deviation (required)

Wrong student details

Wrong medication details

Dose or route details

Timing details

Allergy or contraindication concern details

Immediate Response and Notifications

Was the medication given? (required)

Was the student assessed? (required)

Assessment findings

Immediate actions taken (required)

Who was notified? (required)

Time notifications were made

Notification details

Summarize what was communicated and any instructions received.

Outcome and Follow-Up

Did an adverse reaction occur? (required)

Reaction description

Student disposition (required)

Follow-up required? (required)

Follow-up actions

Return-to-school notes

Submitter and Audit Trail

Completed by (required)

Completion date (required)

Completion time (required)

Reviewed by

Optional supervisor or nurse reviewer for internal audit trail.

Review notes

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Email (required)

Your name (optional)

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