Medication Incident Logout Step 1 of 2 50% REF No: Log No/ Initials of affected party/ DD/MM/YYMedication IncidentLocation Date of Incident Day Month Year Time Hours : Minutes AM PM AM/PM Initials of injured/ affected party: Impact of incident on them: No Harm Harm If "Harm", Please give details below: 1. Involved Person FitzRoy staff (inc. bank) Agency Other 1. If "Other", please state person involved below:1. What Happened Missed Given to the wrong person No signature Not given at correct time Wrong drug given Wrong administration route used Wrong dose given Out of date meds given Other 1. If "Other", please state what happened below:2. Involved Person Person we support Family/representative 2. What Happened Refused: Spat out Vomited after administration Missed Other 2. If "Other", please state what happened below:3. Involved Person Hospital/GP /pharmacy Unknown 3. What Happened Meds supply not available Wrongly dispensed Information incorrect Other 3. If "Other", please state what happened below:Full Details Of EventImmediate action taken in response to the above incident GP advice sought 111 advice sought: No action required Details Of Given AdviceIf Staff/ Bank/ Agency - Please select any considered influences on this shortfall Distraction Fatigue Uncertain of procedure Unclear Instruction Environmental i.e. Space/light: Other If "Other" please give details belowName of person responsible for administering (if known): First Last Name Of Person Completing This Report First Last Date Completed Day Month Year SignatureOptionalResponsible Manager/ On-Call notified:
