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v.04212009

MEDICATION OCCURRENCES	    Department of Developmental Services           

*Individual:  First Name:                                                        *Last Name:      
(* = Required Field)

*(1) Reporting Agency:      

*(2) Responsible Site:      

*(3) Responsible Site Phone Number:       

*(4) Supervisor Responsible for MOR Follow-up:
(4A) First Name:                                                       (4B) Last Name:      
*(5) What Happened?  	
(Omission, Wrong individual, Wrong time, Wrong medication, Wrong route, Wrong dose)
*(6) Date of Medication Occurrence:                                                               * (7) Time:      
 *(8) Date of Discovery:                                                                                   * (9) Time:      

*(10) Did the Medication Occurrence Happen Over Multiple Consecutive Administrations?  YES  NO
*(11) If Yes in #10, Number of Doses:       

*(12) Staff Position of Person Giving Medication:                                                     
	
*(13) Why Did Medication Occurrence Happen:   
                                                                         
*(14) MAP Consultant’s Title: Registered Nurse Registered Pharmacist Health Care Provider (HCP)
                                                                                                          
*(15) MAP Consultant Contacted:  Yes  No
(15A)  First Name:                                                      (15B) Last Name:       

*(16) Date Consultant Contacted:                              *(17) Time Consultant Contacted:      

*(18) Was Medical Intervention Recommended?   YES  NO

(19) If Yes in 18, Check All That Apply:
	 Lab Work	 Other Tests	Health Care Provider (HCP) Visit 
	 Clinic Visit	 Emergency Room Visit  Hospitalization
*(20) Did any of the following situations or conditions result from the medication occurrence (Check All That Apply)?
  	 Illness	 Injury	 Death                                                                                                                                                                 

 (21) Was DPH Notified?   YES  NO
             According to MAP Policy, DPH must be notified if any medical intervention occurred as a result of the    	medication occurrence.  Such medication occurrences are called “HOTLINES”.  Answering “Yes” to Question 	# 18 and selecting any of the choices in Question #20 requires that DPH be notified immediately.  Submit “HOTLINES” within 24 hours of discovery.

(22) Date DPH was Notified:                                         (23) Time:      

MEDICATION OCCURRENCES	    Department of Developmental Services             Page 2 of 3

Individual:  First Name:                                                        Last Name:           

*(24) Was an Incident Report Filed as a Result of the Medication Occurrence?   YES  NO

(25) If Yes in 24, Incident ID, if known:                                                                                                                                                      

*(26) What is the agency’s response to prevent this type of occurrence from happening in the future? 

(27) Additional Comments (Also use if “Other” is selected in #26):      
*(28) Name of Medication(s) as Ordered:    (29) Dosage:              (30) Frequency/Time:  		(31) Route  
       
     	     	     		
     	     	     		
     	     	     		

*(32) Name of Medication(s) as Given:           (33) Dosage:              (34) Frequency/Time:  		(35) Route 

     	     	     		
     	     	     		
     	     	     		

*(36) Number of medications supposed to be given at same time as the medication occurrence including the medication(s) involved in the medication occurrence (check one): 
(0, 1, 2, 3, 4, 5, 6-10, 11-15)
*(37) Was there a recent change in the medication order for the medication(s) involved in the MOR?   YES  NO
(38) If “Yes” in #37, Date of Medication Order Change:      
*(39) Can this medication occurrence be connected to a single staff person?   YES  NO
(40) If Yes in #39, (40A) Staff Person First Name:                                                  
       OPTIONAL                        
                               (40B) Staff Person Last Name:       

(41) If Yes in #39, is the staff person a regular staff member? (Select one)	
YES  NO, Contracted Relief Staff  NO, Agency Relief Staff
							                                                        
(42) If Yes in #39, does this person regularly administer medications as part of their routine responsibility? YES  NO
(43) Was the person who caused the medication occurrence working their regular shift?   
       YES  NO – Different Shift    NO – Overtime Shift
(44) Was the person who caused the medication occurrence working at their routine site?   YES  NO
(45) Submitted by:
(46) Submitted date:
SUBMIT MOR TO MAP COORDINATOR WITHIN 7 BUSINESS DAYS OF DISCOVERY

MEDICATION OCCURRENCES	    Department of Developmental Services             Page 3 of 3

Individual:  First Name:                                                        Last Name:           

MAP COORDINATOR REVIEW

*(47) Review Status:   Approved 	 Not Approved
*(48) Reason for Non-Approval: 	 Referred to Provider for follow-up
				     	 Other
(49) If “Other” in #46, explain:      
(50) Comments/Recommendations: