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506. - Record of Medication Error

506. - Record of Medication Error

Adopted: February 2006
Revised: July 2015

Download 506. - Record of Medication Error



student name                                                                        date of birth



grade                school                                                                                teacher



date of error                                                           time of error



staff member responsible for error                                      position


Current medication order:                                      


medication name        strength                               time to be given                   dosage


Medication error:


medication name      strength                               time given                            dosage


Type of Error: (Check all that apply)


o       Incorrect medication                              o       Incorrect dosage

o       Incorrect route of administration            o       Incorrect student

o       Medication not given                             o       Incorrect time

o       Medication damaged/wasted                  o       Medication duplication

o       Drug count variance


Describe how the error occurred:                                                                                                                                                                                                        


What precautions can be taken to prevent a similar error:                                           





parent notified         when                                                   by whom


physician notified (if applicable)         when                    by whom


health services coordinator notified       date                                                     time



signature of person responsible for error                                date


signature of principal                                                         date


Distribution:  • Original – Sent to Health Services Coordinator

                     • Copy – To remain in school