Procedure Number: NE-06

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Medication Error Reporting Tool 06/29/2015

Pharmacy Name:

Store Location:

Date of Medication Error/Near Miss:

Date Medication Error/Near Miss Identified:

Date Error Reported to Magellan Rx Management:

Definitions

Term Definition

Medication Error “Medication Error” means any dispensing error; medication(s) processed other than in accordance with the physician prescription, including any “near miss” where the error was caught by the Pharmacy prior to the member receiving the medication(s).” Medication errors include any discrepancy in correct drug, correct directions, correct dosage, correct quantity, correct patient, and/or correct labeling.

Near Miss “Near Miss” means the potential medication error was caught before the medication was dispensed to the member.

Member Demographics

Member Name Member ID Member Plan Patient

Member was the patient. Member was NOT the patient

If the member was not the patient (intended recipient of the medication) please enter the following:

Intended Recipient’s Name Age Relationship to Member

Complete the following information regarding the physician’s prescription:

Prescribed Dispensed

Drug Name Drug Dose Drug Quantity Drug Directions Patient Name

Procedure Number: NE-06

Page 2 | Medication Error Reporting Tool

Please provide a narrative description of all pertinent facts surrounding the medication error event addressing at a minimum the questions below (use additional paper if required).

Questions Description

Details of the event.

Was the error caught before the member took their first dose?

How was the error discovered?

Was the prescriber notified? If NO please indicate the reason why.

Yes DATE: No

Was the member notified? If NO please indicate the reason why.

Yes DATE: No

Has the member had any adverse sequela as a result of the event? If YES, please include details.

Unknown Yes

Has the member received the appropriate medication?

If NOT, please explain.

Yes DATE: No

What corrective actions have been implemented to eliminate these types of errors in the future?

Was the claim properly reprocessed?

If not, why.

Yes DATE: No

Name of Pharmacist Completing Form:

Telephone Number:

Signature:

Date:

Procedure Number: NE-06

Medication Error Reporting Tool | Page 3

The following sections are to be completed by Magellan Rx Management personnel.

Magellan Rx Management Clinical Review Results/Actions

Does the report contain sufficient information for analysis? Yes No Unknown

Are additional contacts to member warranted? Yes No Unknown

Are additional contacts to prescriber warranted? Yes No Unknown

Any additional comments or actions taken as a result of the clinical review?

Clinical Review Conducted by: Date sent to Network:

Magellan Rx Management Network Review Results/Actions

Network Review Conducted by: Date received by Network:

Does the report represent a potential trend? Yes No Unknown

Are actions against the pharmacy warranted at this time? Yes No Unknown

Any additional comments or actions taken as a result of the network review?

If yes, please indicate date(s)

Date Reported to QIC: