Adopted: February 2006
Revised: July 2015
Download 506.2.2.4.1P - 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