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:
