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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).

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Incident
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Outcome
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Medication(s)
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Follow Up
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Patient
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Reporter
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Contributing Factors
*Indicates Required Fields (Total of nine required fields.)

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Date of Incident:
Time of Incident: 
Incident Description / How Discovered:*
Stages Involved:*
Type of Incident:*

Discovered By:*
Care Area Type:*
Severity / Outcome:*
 
Intervention:
Medication 1 Medication 2
Medication Name:*
Strength:
Route of Administration:
Manufacturer:
Lot Number:
Confusing drug name, label or packaging:*

 

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:

I may be contacted by ISMP Canada for follow-up about this medication incident:*

 

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.

For our
consumer-focused website:

SafeMedicationUse.ca

Participate in our
Community Pharmacy Incident Reporting Program:

Community Pharmacy Incident Reporting (CPhIR) Program