| 1. Date the incident occurred |
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| 2. Province or Territory |
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| 3. What type of medication incident are you reporting? * |
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| 4. Where did the incident happen? * |
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| 5. At what stage(s) of the medication system did the incident occur? (Choose all that apply.) * |
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| 6. Name of medication(s) involved in this incident * |
| Medication: * |
Dosage Form: |
Strength: |
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| 7. Who discovered the incident? * |
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| 8. What was the age range of the person or patient who was affected by this incident? |
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| 9. Which of these most accurately describes the harm from the incident? * |
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Did not reach the patient:
For example, a hazardous situation.
No harm:
No symptoms detected, no treatment required.
Mild harm:
The symptoms were mild, temporary and short term and no treatment or minor treatment was required.
Moderate harm:
The symptoms required initial or additional treatment or an operation, or the incident kept the patient in hospital longer than expected.
Severe harm:
The symptoms required major treatment to save the patient's life, the incident shortened life expectancy or caused major permanent or long term harm.
Death:
There is reason to believe that the incident may have contributed to the patient's death or hastened the patient's death.
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| 10. What needed to be done because of this incident? (Choose all that apply) |
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| 11. Please describe what happened. If you have any suggestions on how an incident like this one can be prevented in the future, please include them. |
Reminder: Please do not include any information that would identify the person involved, such as name, relationship to the reporter, address, or health number.
Please do not include the name(s) of health professionals or healthcare organizations involved in the incident.
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12.
Would you like to give ISMP Canada permission to contact you with any follow-up questions?
Contact Permission
Providing contact information allows ISMP Canada to contact you if we need more information to help us learn from your report. ISMP Canada will only contact you for the purpose of follow up, for example, if we need clarification about your description of the incident. After the incident report is reviewed and analyzed, ISMP Canada will not keep information that could identify individuals who agreed to be contacted.
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No, do not contact me.
Yes, I give ISMP Canada permission to contact me with any follow-up questions. By providing your contact information, you are consenting to be contacted by ISMP Canada for this purpose.
Here is my contact information.
Email
Name
Phone Number
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Before submitting your report, please review and accept our terms.
This website does not provide medical advice. If you require medical advice, contact your healthcare provider or, if you
think you may have a medical emergency, call 911.
Before submitting your report, it is important that you read, understand and accept the following:
1. The Institute for Safe Medication Practices Canada (ISMP Canada) cannot investigate complaints about
individual cases with the healthcare organization or professional that provided your care. Information on what
to do to resolve a concern about the safety of your care is available on the website of the Canadian Patient
Safety Institute under "Patient Concern Resolution Process".
2. ISMP Canada does not need to collect information that identifies a patient
or that could be combined with other information to identify a patient. We
cannot accept a report that includes a name, address, telephone number, fax,
email address, health care number, or any other information that could
identify an individual patient. If you are reporting an incident that
happened to someone else, please do not use terms that might identify an
individual or your
relationship with an individual (for example "he/she", "son/daughter", "husband/wife", "mother/father").
3. Please do not include the name(s) of health professionals or healthcare
organizations in your report.
4. You will be invited to provide your contact information at the end of
the reporting process, for follow-up purposes. Providing contact information
is optional. By providing your contact information, you are consenting to be
contacted by ISMP Canada. After the incident report is fully reviewed and
analyzed, ISMP Canada will not keep information that could identify
individuals who agreed to be contacted.
5. By submitting your report, you are giving ISMP Canada your permission to use the information you provide in
order to learn about safe medication use. ISMP Canada will be free to reproduce, use, and distribute such
information to others for the purpose of recommending safe medication practices and alerting others to prevent
harmful incidents, but ISMP Canada will protect your privacy. For details on how we will protect your privacy, click here.
I have read, understood and accept these terms. *
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