1. Where did the error happen?  *
2. At what point did the error occur? (choose all that apply) *
  • Prescribing
  • Documentation/computer entry
  • Dispensing
  • Administration
  • Monitoring
  • Other
  • I don't know
3. What medication(s) were involved? *
Medication name *
Dosage form
Strength
4. What type of error occurred? *
5. Was the patient harmed because of the error? *
  • Did not reach the patient ?
  • No harm ?
  • Mild harm ?
  • Moderate harm ?
  • Severe harm ?
  • Death ?
6. Tell us what happened in your own words.
Do not include identifying information such as health card numbers, addresses, or names of individuals, health care providers, pharmacies, or organizations. If you have suggestions to prevent the error from happening again, please include them here.

7. What steps were taken because of the error? (choose all that apply)
  • Called doctor, nurse or pharmacist
  • Visited Doctor's Office or Clinic
  • Called Poison Control Centre
  • Called 911
  • Received more treatment
  • Received medical test(s)
  • Visited Emergency Department
  • Admitted to Hospital
  • Extended an existing hospital stay
  • Nothing
  • Other
8. What was the age of the person affected by the error?
9. Who discovered the error?
10. Date the error occurred
11. Province / Territory
12. Do you give permission for ISMP Canada to contact you to learn more about the error?
Yes – I give permission
No – Do not contact me
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  • I have read, understood and accept these terms. *