School Health Medication Error Report Form

Purpose: 

To collect data regarding reportable medication errors in schools, per 105 CMR 210.009 (B), in order to monitor and improve medication administration practices in school. 

Regulatory Requirement: 

Medication errors that are reportable to MDPH School Health Services via this form, under 105 CMR 210.009 (B) are "all medication errors resulting in serious illness requiring medical care". 

Any medication error that did not result in serious illness requiring medical care "shall be documented by the school nurse on an accident/incident report form. These reports shall be retained in a location as determined by school policy and made available to the Department of Public Health upon request." 

Instructions: 

For all medication errors in schools, follow internal procedures regarding necessary notifications and accident/incident reporting. 

Use this form to report all medication errors resulting in serious illness requiring medical care to MDPH.  

This form should be completed by the school nurse leader or school nurse responsible for the error. 

For questions, please review the Medication Error Report Guide and if they are not answered there, email medication.delegation@mass.gov 

Diversion: 

All incidents of theft, loss, or suspected tampering of drugs should be reported to the local police as well as MDPH's Drug Control Program per 105 CMR 700.005 (D), using a separate form using the link below. 

Link: https://www.mass.gov/how-to/submit-a-drug-incident-report-dir 

Error made by:

You MUST click this link before you hit submit below.

Clicking the link will open a separate tab where you will read about how to report all incidents of theft, loss, or suspected tampering of drugs to the Drug Control Program (DCP), which is required per 105 CMR 700.005 (D).

In addition to submitting the report to DCP, you, or someone on your team, should also report this incident to the local police.

To save your report so you can finish it or edit it later, click Save & Return Later, and then bookmark this page. You can also have the Survey Link for this report sent to your email address. To do that, just follow the instructions on the screen that pops up after you click Save & Return Later. If you need to edit your report later but do not have the Survey Link and have not bookmarked the page, then you will not be able to edit your report and you will need to re-submit the report and re-enter all of your data. When we receive more than 1 report for the same incident, we save only the more recently submitted report and discard any earlier reports.  

Save a copy of your report before you submit it. We will not be able to retrieve your report and send it to you.  You can download a pdf copy after you click submit, but to save a more readable copy, before you click submit, print to a pdf file or print a hard copy of the page (right-click on the page and select Print).  

When you have completed the report, click Submit. You will not receive an email confirming your data submission, but you will see a "Thank you" message on screen when you have successfully submitted a report.