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A pilot project of the Canadian Medication Incident Reporting and Prevention System (CMIRPS).

Incident Report:

NOTE: Red Asterisks * indicate which fields are REQUIRED.
1. Date the incident occurred
2. Province or Territory
3. What type of medication incident are you reporting? *
4. Where did the incident happen? *
5. At what stage(s) of the medication system did the incident occur? (Choose all that apply.) *
6. Medication(s) involved in this incident *
Medication: * Dosage Form: Strength:
7. Who discovered the incident? *
8. What was the age range of the person or patient who was affected by this incident?
9. Which of these most accurately describes the harm from the incident? *
10. What needed to be done because of this incident? (Choose all that apply)
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.

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.
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.

  Before submitting your report, please review and accept our terms.

I have read, understood and accept these terms. *

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