Appendix H: Actual/Near Miss Medication Error Feedback Report
The program would like to track actual and near miss errors in medication administration.
In addition to completing necessary agency documentation, please complete the Actual/Potential Medication Error Feedback Report with the student. Keep one copy to attach to the student’s final professional practice evaluation, give a copy to the student, and forward one copy to the Professional Practice Coordinator.
*To be used when actual/potential medication error made. May be accompanied by interview record.*
| Student’s Name | |
| Date of Potential/Actual Medication Error |
| Medication Ordered | Medication Prepared |
| Date and Time | |
| Description of Actual/Potential Medication Error | |
| Contributing Factors | • Individual
• Unit • Systems Details |
| Actions to be Taken by Student |
Date of Interview: Date for Follow-up:
Student Signature: Faculty Signature:
