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.) *
  • Prescribing
  • Documentation/computer entry
  • Preparation/dispensing
  • Administration
  • Monitoring
  • Other
  • I don't know
6. Name of 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? *
  • Did not reach the patient/consumer ?
  • No harm ?
  • Mild harm ?
  • Moderate harm ?
  • Severe harm ?
  • Death ?
10. What needed to be done because of this incident? (Choose all that apply)
  • Called doctor, nurse or pharmacist
  • Visited Doctor's Office or Clinic
  • Called Poison Control Centre
  • Called 911
  • More treatment
  • Medical test(s)
  • Visited Emergency Department
  • Admitted to Hospital
  • Extended an existing hospital stay
  • Nothing
  • Other
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?
  • 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. *