ADVERSE MEDICINES EVENTS LINE

Reporting a Medicine Incident or Error

Complete this form to report a Medicine Incident or Error. If you wish to report a suspected adverse reaction, go to the Reporting Side Effects form.

Who had the medication incident?

Gender:

Male
Female

Postcode:

If not in Australia, what country?

Age:

 years

 months ( if baby )

Report submitted by?

Consumer (self)
Relative
Doctor
Other

If other, please specify:

What type of medicine incident do you want to report?

Error causing injury
Close call
Error not causing injury
Quality issue

Do you think the incident was preventable?

Yes
No

If yes, why do you think the incident was preventable?

About the medicine(s) you suspect caused the incident:
 (Details can be found on the label or packaging)

Medicine 1

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

Medicine 2

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

Medicine 3

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

List other medicines (or herbal remedies) by brand name taken within 3 months of the incident?
Details can be found on the label or packaging.

Date of incident or symptoms:

-- dd/mm/yy or approximate date

Description of the incident or symptoms

Do you think that any of the following factors contributed to the medicine incident?
(check all that apply)

    Communication     Media (print, radio, TV)
    Consumer Medicines Information Leaflet     Monitoring
    Drug/medicine abuse     Training Issues
    Equipment or device     Workload
    Labelling     Other (please specify)
    Language difficulty  

If other, please specify.

Outcomes attributed to the medicine incident
(check all that apply)

    Nil    Birth Defect
    Death    GP Consultation
    Danger to life    Worsened quality of life
    Hospital Admission    Absence from Productive Activity (eg time off work)
    Hospital Stay Prolonged    Ongoing Treatment Required (eg physio, rehab)
    Hospital Visit, Not Admitted  

Did this medicine incident result in any medicine changes?
(check all that apply)

Dose changed    Drug continued  Drug ceased     Drug Replaced

Your own story

Optional Information:

Contact information:

Name
Telephone(incl STD code)
E-mail
Funded by The National Prescribing Service,  operated by Mater Misericordiae Health Services Brisbane Limited. NPS is a non-profit, independent organisation for Quality Use of Medicines funded by the Australian Government Department of Health and Ageing
Adverse Medicines Events Line
Copyright © 2005  All rights reserved.
Revised: 17-May-2005