F-12-502 QI Reporting: Medication Errors

🎯 PURPOSE

This process describes how and when to complete a QI Report that involves a Medication Error. Refer to policy A-3-441 Medication Error for additional definition and description of identifying, reporting and reviewing medication errors.

Medication Error Definition:

A medication error is defined as any error, significant or not significant which includes:

All errors in wrong medication, wrong time, wrong dose, extra dose, wrong route of administration, omission of ordered dose (not related to client/caregiver noncompliance) or length of infusion
Incorrect label, storage or preparation of medication
Missing a scheduled administration of a medication for any reason (eg. staffing difficulties, equipment, supplies)
Loss or spillage of medication

🔄 PROCESS

Clinician will complete a QI Report in PointCare. If the medication error involves a client that does not have an Electronic Health Record (EHR) in HCHB, then an external Unusual Occurrence Report document will be completed. Refer to F-13-501 Occurrence Reporting: Adara External Occurrence Reports.

Refer to F-12-500 Create QI Report in PointCare for detailed description of how to add a QI report within a visit or in the medical record.

NOTE: If medication error is documented inside of a visit, it will not sync to the back office until the visit is synced. If it is documented in the medical record outside of a visit, it will sync to the back office the next time the device is synced when completed

Select Med Errors:

Select Add:

Enter Med Error Date from calendar:

Enter who discovered the error:

Enter the Date the error was discovered:

Med Error Description: describe what happened including the specific details of the suspected error, medication(s) and dosages involved, dates/times, any person(s) involved, etc:

Med Error Type: Click on “select” to choose the most appropriate Medication Error Type(s):

Select all that apply:

Medications Involved: select “add” to access medication database to select medication(s) involved:
1. Enter the name of the medication and select Full Search:

b. Select appropriate medication:

c. Repeat for any additional medications as needed.

d. Medication(s) will be listed. Select Delete if needing to adjust:

Notifications: Notify the supervisor and provider. Check box appropriately:
Select “Add” to add the names of people notified:

a. Enter the name of individual notified

b. Update date if needed:

c. Select Save:

d. Repeat as needed to add additional individuals notified

e. Names will be listed. Select Delete if needing to adjust:

Outcome: Document what was the result and immediate follow up actions. Address how the client’s immediate needs were met and actions taken to prevent re-occurrence:

Select Save:

Refer to the following processes for detailed directions on each QI Report type:

Client Occurrence: F-12-501 QI Reporting: Client Occurrence
Vulnerable Adult/Child Reporting: F-12-505 QI Reporting: Vulnerable Adult/Minor Reporting
Witnessed/Unwitnessed Falls: F-12-506 QI Reporting: Witnessed/Unwitnessed Falls
Medication Errors: F-12-502 QI Reporting: Medication Errors
Complaint: F-12-503 QI Reporting: Complaint
Infection Occurrence: F-12-504 QI Reporting: Infection Occurrence
Adara External Occurrence Reports: F-13-501 Occurrence Reporting: Adara External Occurrence Reports

📅 Effective: 08/17/2026 | 🛠️ Revised: | ✅ Approved: JS