Purpose: To track all medication variances resulting in medical intervention. To improve the quality of medication administration practices in schools. Regulatory Requirement: Medication errors, as defined in 105 CMR 210.005(F) (5), resulting in serious illness requiring medical care shall be reported to the Department of Public Health 105 CMR 210.009(6) (B). Instructions: For ALL variances, notify your nurse leader/ supervisor and principal/ superintendent immediately. All medication errors resulting in serious illness requiring medical care shall be reported to the Department of Public Health, Bureau of Community Health and Prevention. 1. Form to be completed by the School Nurse Leader or School Nurse. 2. If you have questions, contact Jill Connolly at Jill.E.Connolly@mass.gov Diversion: All incidents of suspected diversion or tampering of drugs should be reported to the local police as well as the MDPH, Drug Control Program......105 CMR 700.005(D) Link: https://www.mass.gov/how-to/submit-a-drug-incident-report-dir Which are you reporting today?
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Medication Error Medication Loss/Diversion
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Public school district (local, regional, vocational, school union) Charter school Collaborative Nonpublic school Other
School District:
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ABBY KELLEY FOSTER CHARTER PUBLIC (DISTRICT) ABINGTON ACADEMY OF THE PACIFIC RIM CHARTER PUBLIC (DISTRICT) ACCEPT EDUCATION COLLABORATIVE ACTON-BOXBOROUGH ACUSHNET ADAMS-CHESHIRE ADVANCED MATH AND SCIENCE ACADEMY CHARTER (DISTRICT) AGAWAM ALMA DEL MAR CHARTER SCHOOL (DISTRICT) AMESBURY AMHERST AMHERST-PELHAM AMHERST-PELHAM (REGIONAL+ SCHOOL UNION 26) AMHERST-PELHAM (SCHOOL UNION 26) ANDOVER ARGOSY COLLEGIATE CHARTER SCHOOL (DISTRICT) ARLINGTON ASHBURNHAM-WESTMINSTER ASHLAND ASSABET VALLEY COLLABORATIVE ASSABET VALLEY REGIONAL VOCATIONAL TECHNICAL ATHOL-ROYALSTON ATLANTIS CHARTER (DISTRICT) ATTLEBORO AUBURN AVON AYER SHIRLEY SCHOOL DISTRICT BARNSTABLE BAYSTATE ACADEMY CHARTER PUBLIC SCHOOL (DISTRICT) BEDFORD BELCHERTOWN BELLINGHAM BELMONT BENJAMIN BANNEKER CHARTER PUBLIC (DISTRICT) BENJAMIN FRANKLIN CLASSICAL CHARTER PUBLIC (DISTRICT) BENTLEY ACADEMY CHARTER SCHOOL (DISTRICT) BERKLEY BERKSHIRE ARTS AND TECHNOLOGY CHARTER PUBLIC (DISTRICT) BERKSHIRE HILLS BERLIN BERLIN BOYLSTON (SCHOOL UNION 60) BERLIN-BOYLSTON BERLIN-BOYLSTON (REGIONAL+ SCHOOL UNION 60) BEVERLY BI-COUNTY COLLABORATIVE (BICO) BILLERICA BLACKSTONE VALLEY REGIONAL VOCATIONAL TECHNICAL BLACKSTONE-MILLVILLE BLUE HILLS REGIONAL VOCATIONAL TECHNICAL BOSTON BOSTON COLLEGIATE CHARTER (DISTRICT) BOSTON DAY AND EVENING ACADEMY CHARTER (DISTRICT) BOSTON GREEN ACADEMY HORACE MANN CHARTER SCHOOL (DISTRICT) BOSTON PREPARATORY CHARTER PUBLIC (DISTRICT) BOSTON RENAISSANCE CHARTER PUBLIC (DISTRICT) BOURNE BOXFORD BOYLSTON BRAINTREE BREWSTER BRIDGE BOSTON CHARTER SCHOOL (DISTRICT) BRIDGEWATER-RAYNHAM BRIMFIELD BRISTOL COUNTY AGRICULTURAL BRISTOL-PLYMOUTH REGIONAL VOCATIONAL TECHNICAL BROCKTON BROOKE CHARTER SCHOOL (DISTRICT) BROOKE CHARTER SCHOOL EAST BOSTON (DISTRICT) BROOKE CHARTER SCHOOL MATTAPAN (DISTRICT) BROOKE CHARTER SCHOOLS (ALL CAMPUSES) BROOKFIELD BROOKLINE BURLINGTON C.A.S.E. CONCORD AREA SPED COLLABORATIVE CAMBRIDGE CANTON CAPE COD COLLABORATIVE CAPE COD LIGHTHOUSE CHARTER (DISTRICT) CAPE COD REGIONAL VOCATIONAL TECHNICAL CAPS EDUCATION COLLABORATIVE CARLISLE CARVER CENTRAL BERKSHIRE CENTRAL MASSACHUSETTS SPED COLLABORATIVE CHELMSFORD CHELSEA CHESTERFIELD-GOSHEN CHICOPEE CHRISTA MCAULIFFE CHARTER PUBLIC (DISTRICT) CITY ON A HILL CHARTER PUBLIC SCHOOL CIRCUIT STREET (DISTRICT) CITY ON A HILL CHARTER PUBLIC SCHOOL DUDLEY SQUARE (DISTRICT) CITY ON A HILL CHARTER PUBLIC SCHOOL NEW BEDFORD (DISTRICT) CLARKSBURG CLINTON CODMAN ACADEMY CHARTER PUBLIC (DISTRICT) COHASSET COLLABORATIVE FOR EDUCATIONAL SERVICES COLLABORATIVE FOR REGIONAL EDUCATIONAL SERVICES & TRAINNG (CREST) COLLEGIATE CHARTER SCHOOL OF LOWELL (DISTRICT) COMMUNITY CHARTER SCHOOL OF CAMBRIDGE (DISTRICT) COMMUNITY DAY CHARTER (ALL CAMPUSES) COMMUNITY DAY CHARTER PUBLIC SCHOOL - GATEWAY (DISTRICT) COMMUNITY DAY CHARTER PUBLIC SCHOOL - PROSPECT (DISTRICT) COMMUNITY DAY CHARTER PUBLIC SCHOOL - R. KINGMAN WEBSTER (DISTRICT) CONCORD CONCORD-CARLISLE CONSERVATORY LAB CHARTER (DISTRICT) CONWAY DANVERS DARTMOUTH DEDHAM DEERFIELD DENNIS-YARMOUTH DIGHTON-REHOBOTH DOUGLAS DOVER DOVER-SHERBORN DOVER-SHERBORN (REGIONAL+ SCHOOL UNION 50) DOVER-SHERBORN (SCHOOL UNION 50) DRACUT DUDLEY STREET NEIGHBORHOOD CHARTER SCHOOL (DISTRICT) DUDLEY-CHARLTON REG DUXBURY EAST BRIDGEWATER EAST LONGMEADOW EASTHAM EASTHAMPTON EASTON EDCO COLLABORATIVE EDGARTOWN EDWARD M. KENNEDY ACADEMY FOR HEALTH CAREERS (HORACE MANN CHARTER) (DISTRICT) ERVING ERVING (SCHOOL UNION 28) ESSEX NORTH SHORE AGRICULTURAL AND TECHNICAL SCHOOL DISTRICT EVERETT EXCEL ACADEMY CHARTER (DISTRICT) FAIRHAVEN FALL RIVER FALMOUTH FARMINGTON RIVER REG FITCHBURG FLLAC COLLABORATIVE FLORIDA FOUR RIVERS CHARTER PUBLIC (DISTRICT) FOXBOROUGH FOXBOROUGH REGIONAL CHARTER (DISTRICT) FRAMINGHAM FRANCIS W. PARKER CHARTER ESSENTIAL (DISTRICT) FRANKLIN FRANKLIN COUNTY REGIONAL VOCATIONAL TECHNICAL FREETOWN-LAKEVILLE FRONTIER FRONTIER (REGIONAL+ SCHOOL UNION 38) FRONTIER (SCHOOL UNION 38) GARDNER GATEWAY GEORGETOWN GILL-MONTAGUE GLOBAL LEARNING CHARTER PUBLIC (DISTRICT) GLOUCESTER GOSNOLD GRAFTON GRANBY GREATER FALL RIVER REGIONAL VOCATIONAL TECHNICAL GREATER LAWRENCE REGIONAL VOCATIONAL TECHNICAL GREATER LOWELL REGIONAL VOCATIONAL TECHNICAL GREATER NEW BEDFORD REGIONAL VOCATIONAL TECHNICAL GREENFIELD GREENFIELD COMMONWEALTH VIRTUAL DISTRICT GROTON-DUNSTABLE HADLEY HALIFAX HAMILTON-WENHAM HAMPDEN CHARTER SCHOOL OF SCIENCE EAST (DISTRICT) HAMPDEN CHARTER SCHOOL OF SCIENCE WEST (DISTRICT) HAMPDEN-WILBRAHAM HAMPSHIRE HAMPSHIRE (REGIONAL+ SCHOOL UNION 66) HAMPSHIRE (SCHOOL UNION 66) HANCOCK HANOVER HARVARD HATFIELD HAVERHILL HAWLEMONT HELEN Y. DAVIS LEADERSHIP ACADEMY CHARTER PUBLIC (DISTRICT) HILL VIEW MONTESSORI CHARTER PUBLIC (DISTRICT) HILLTOWN COOPERATIVE CHARTER PUBLIC (DISTRICT) HINGHAM HOLBROOK HOLLAND HOLLISTON HOLYOKE HOLYOKE COMMUNITY CHARTER (DISTRICT) HOPEDALE HOPKINTON HUDSON HULL INNOVATION ACADEMY CHARTER (DISTRICT) INSTITUTIONAL SCHOOLS IPSWICH KING PHILIP KINGSTON KIPP ACADEMY BOSTON CHARTER SCHOOL (DISTRICT) KIPP ACADEMY LYNN CHARTER (DISTRICT) LABBB COLLABORATIVE LANESBOROUGH LAWRENCE LAWRENCE FAMILY DEVELOPMENT CHARTER (DISTRICT) LEE LEE-TYRINGHAM (SCHOOL UNION 29) LEICESTER LENOX LEOMINSTER LEVERETT LEXINGTON LIBERTAS ACADEMY CHARTER SCHOOL (DISTRICT) LINCOLN LINCOLN-SUDBURY LITTLETON LONGMEADOW LOWELL LOWELL COMMUNITY CHARTER PUBLIC (DISTRICT) LOWELL MIDDLESEX ACADEMY CHARTER (DISTRICT) LOWER PIONEER VALLEY EDUCATIONAL COLLABORATIVE LUDLOW LUNENBURG LYNN LYNNFIELD MA ACADEMY FOR MATH AND SCIENCE MALDEN MANCHESTER ESSEX REGIONAL MANSFIELD MAP ACADEMY CHARTER SCHOOL (DISTRICT) MARBLEHEAD MARBLEHEAD COMMUNITY CHARTER PUBLIC (DISTRICT) MARION MARLBOROUGH MARSHFIELD MARTHA'S VINEYARD MARTHA'S VINEYARD (REGIONAL+ SCHOOL UNION 19) MARTHA'S VINEYARD (SCHOOL UNION 19) MARTHA'S VINEYARD CHARTER (DISTRICT) MARTIN LUTHER KING JR. CHARTER SCHOOL OF EXCELLENCE (DISTRICT) MASCONOMET MASCONOMET (REGIONAL + TRI-TOWN SCHOOL UNION 58) MASHPEE MATCH CHARTER PUBLIC SCHOOL (DISTRICT) MATTAPOISETT MAYNARD MEDFIELD MEDFORD MEDWAY MELROSE MENDON-UPTON METHUEN MIDDLEBOROUGH MIDDLETON MILFORD MILLBURY MILLIS MILTON MINUTEMAN REGIONAL VOCATIONAL TECHNICAL MOHAWK TRAIL MONOMOY REGIONAL SCHOOL DISTRICT MONSON MONTACHUSETT REGIONAL VOCATIONAL TECHNICAL MOUNT GREYLOCK MYSTIC VALLEY REGIONAL CHARTER (DISTRICT) NAHANT NANTUCKET NARRAGANSETT NASHOBA NASHOBA VALLEY REGIONAL VOCATIONAL TECHNICAL NATICK NAUSET NAUSET (REGIONAL+ SCHOOL UNION 54) NAUSET (SCHOOL UNION 54) NEEDHAM NEIGHBORHOOD HOUSE CHARTER (DISTRICT) NEW BEDFORD NEW HEIGHTS CHARTER SCHOOL OF BROCKTON (DISTRICT) NEW SALEM-WENDELL NEWBURYPORT NEWTON NORFOLK NORFOLK COUNTY AGRICULTURAL NORTH ADAMS NORTH ANDOVER NORTH ATTLEBOROUGH NORTH BROOKFIELD NORTH MIDDLESEX NORTH READING NORTH RIVER COLLABORATIVE NORTHAMPTON NORTHAMPTON-SMITH VOCATIONAL AGRICULTURAL NORTHBORO-SOUTHBORO NORTHBORO-SOUTHBORO (REGIONAL+ SCHOOL UNION 3) NORTHBOROUGH NORTHBOROUGH-SOUTHBOROUGH (SCHOOL UNION 3) NORTHBRIDGE NORTHEAST METROPOLITAN REGIONAL VOCATIONAL TECHNICAL NORTHERN BERKSHIRE (SCHOOL UNION 43) NORTHERN BERKSHIRE REGIONAL VOCATIONAL TECHNICAL NORTHSHORE EDUCATION CONSORTIUM NORTON NORWELL NORWOOD OAK BLUFFS OLD COLONY REGIONAL VOCATIONAL TECHNICAL OLD ROCHESTER OLD ROCHESTER (REGIONAL+ SCHOOL UNION 55) OLD ROCHESTER (SCHOOL UNION 55) OLD STURBRIDGE ACADEMY CHARTER PUBLIC SCHOOL (DISTRICT) ORANGE ORLEANS OTHER OXFORD PALMER PATHFINDER REGIONAL VOCATIONAL TECHNICAL PAULO FREIRE SOCIAL JUSTICE CHARTER SCHOOL (DISTRICT) PEABODY PELHAM PEMBROKE PENTUCKET PETERSHAM PHOENIX ACADEMY PUBLIC CHARTER HIGH SCHOOL LAWRENCE (DISTRICT) PHOENIX ACADEMY PUBLIC CHARTER HIGH SCHOOL SPRINGFIELD (DISTRICT) PHOENIX CHARTER ACADEMY (DISTRICT) PILGRIM AREA COLLABORATIVE (PAC) PIONEER CHARTER SCHOOL OF SCIENCE (DISTRICT) PIONEER CHARTER SCHOOL OF SCIENCE II (PCSS-II) (DISTRICT) PIONEER VALLEY PIONEER VALLEY CHINESE IMMERSION CHARTER (DISTRICT) PIONEER VALLEY PERFORMING ARTS CHARTER PUBLIC (DISTRICT) PITTSFIELD PLAINVILLE PLYMOUTH PLYMPTON PROJECT SPOKE COLLABORATIVE PROSPECT HILL ACADEMY CHARTER (DISTRICT) PROVINCETOWN QUABBIN QUABOAG REGIONAL QUINCY RALPH C MAHAR RANDOLPH READING READS COLLABORATIVE REVERE RICHMOND RISING TIDE CHARTER PUBLIC (DISTRICT) RIVER VALLEY CHARTER (DISTRICT) ROCHESTER ROCKLAND ROCKPORT ROWE ROXBURY PREPARATORY CHARTER (DISTRICT) SABIS INTERNATIONAL CHARTER (DISTRICT) SALEM SALEM ACADEMY CHARTER (DISTRICT) SANDWICH SAUGUS SAVOY SCITUATE SEEKONK SEEM COLLABORATIVE SEVEN HILLS CHARTER PUBLIC (DISTRICT) SHAKER MOUNTAIN (SCHOOL UNION 70) SHARON SHAWSHEEN VALLEY REGIONAL VOCATIONAL TECHNICAL SHERBORN SHORE EDUCATIONAL COLLABORATIVE SHREWSBURY SHUTESBURY SILVER HILL HORACE MANN CHARTER (DISTRICT) SILVER LAKE SILVER LAKE (REGIONAL+ SCHOOL UNION 31) SILVER LAKE (SCHOOL UNION 31) SIZER SCHOOL: A NORTH CENTRAL CHARTER ESSENTIAL (DISTRICT) SOMERSET SOMERSET BERKLEY REGIONAL SCHOOL DISTRICT SOMERVILLE SOUTH COAST EDUCATIONAL COLLABORATIVE SOUTH HADLEY SOUTH MIDDLESEX REGIONAL VOCATIONAL TECHNICAL SOUTH SHORE CHARTER PUBLIC (DISTRICT) SOUTH SHORE EDUCATIONAL COLLABORATIVE SOUTH SHORE REGIONAL VOCATIONAL TECHNICAL SOUTHAMPTON SOUTHBOROUGH SOUTHBRIDGE SOUTHEASTERN MASS. EDUCATIONAL COLLABORATIVE (SMEC) SOUTHEASTERN REGIONAL VOCATIONAL TECHNICAL SOUTHERN BERKSHIRE SOUTHERN WORCESTER COUNTY EDUCATIONAL COLLABORATIVE SOUTHERN WORCESTER COUNTY REGIONAL VOCATIONAL TECHNICAL SOUTHWICK-TOLLAND-GRANVILLE REGIONAL SCHOOL DISTRICT SPENCER-E BROOKFIELD SPRINGFIELD SPRINGFIELD PREPARATORY CHARTER SCHOOL (DISTRICT) STONEHAM STOUGHTON STURBRIDGE STURGIS CHARTER PUBLIC (DISTRICT) SUDBURY SUNDERLAND SUTTON SWAMPSCOTT SWAMPSCOTT (INCLUDING NAHANT) SWANSEA TANTASQUA TANTASQUA (REGIONAL+ SCHOOL UNION 61) TANTASQUA (SCHOOL UNION 61) TAUNTON TEC CONNECTIONS ACADEMY COMMONWEALTH VIRTUAL SCHOOL DISTRICT TEWKSBURY THE EDUCATION COOPERATIVE (TEC) TISBURY TOPSFIELD TRI-COUNTY REGIONAL VOCATIONAL TECHNICAL TRITON TRI-TOWN (SCHOOL UNION 58) TRURO TYNGSBOROUGH UP ACADEMY CHARTER SCHOOL OF BOSTON (DISTRICT) UP ACADEMY CHARTER SCHOOL OF DORCHESTER (DISTRICT) UP ACADEMY CHARTER SCHOOL OF SPRINGFIELD UP-ISLAND REGIONAL UPPER CAPE COD REGIONAL VOCATIONAL TECHNICAL UXBRIDGE VALLEY COLLABORATIVE VERITAS PREPARATORY CHARTER SCHOOL (DISTRICT) WACHUSETT WAKEFIELD WALES WALPOLE WALTHAM WARE WAREHAM WATERTOWN WAYLAND WEBSTER WELLESLEY WELLFLEET WEST BOYLSTON WEST BRIDGEWATER WEST SPRINGFIELD WESTBOROUGH WESTFIELD WESTFORD WESTHAMPTON WESTON WESTPORT WESTWOOD WEYMOUTH WHATELY WHITMAN-HANSON WHITTIER REGIONAL VOCATIONAL TECHNICAL WILLIAMSBURG WILLIAMSTOWN WILLIAMSTOWN-LANESBOROUGH (SCHOOL UNION 71) WILMINGTON WINCHENDON WINCHESTER WINTHROP WOBURN WORCESTER WORTHINGTON WRENTHAM OTHER
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Other district (please specify):
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Incident Occurred at (Name of School):
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School registered with MDPH for medication delegation?
Yes
No
Date of Incident:
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Today M-D-Y Click to select a date (M-D-Y)
Now H:M Click to select a time(H:M)
Person affected:
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Student
Staff
Other
Other person (Please describe)
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Classroom
Health Office
Field Trip
Other
If other, please specify:
Incident Type:
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Wrong dose
Wrong medication
Wrong Route
Wrong time
Wrong individual
Please enter Licensed Physician/Practitioner's intended Medication order:
Contributing factors (check all that apply):
Please indicate all who were notified:
Adverse reaction because of error:
Yes
No
Please describe any adverse reaction:
Dismissed without being sent to the ER or hospitalized
Transferred to emergency room:
Yes
No
Yes
No
Today M-D-Y Click to select a date (M-D-Y)
Today M-D-Y Click to select a date (M-D-Y)
Did a debriefing meeting occur?
Yes
No
Is there a full-time School Nurse Leader in your district?
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Yes
No
Are there other nurses available to assist (substitute nurses, resources nurses, float nurses) in the school building where this incident occurred?
Yes
No
Was there an identified systems issue that contributed toward this occurrence?
Yes
No
Was the nurse involved in this incident the full-time school nurse in the school building where the incident occurred?
Yes
No
Other
Recommendation for change(s):
Name:
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Title:
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Today M-D-Y Click to select a date (M-D-Y)
Work
Cell
E-mail address:
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Date sent to MDPH School Health Unit:
Today M-D-Y Click to select a date (M-D-Y)
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Does this report involve a valid medication error?
Yes, it is a valid medication error
No, it is not a valid medication error
NA, it is a medication loss/diversion
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