MEDICATION OCCURRENCE REPORT (MOR) 
1.	
Who completed form?: ______________________
Reviewer: __________________________
		(signature)
Reviewer: write additional comments on the back

Name of Individual: ______________________
2.	Street Address: __________________________
3.	Phone number at the program: ______________
4.	Program Director Name: ___________________
5.	What happened? (Check one)
 Omission	 Wrong time	 Wrong Route	      Wrong Dose
1	Wrong Person    Wrong Medication
6.	Date of medication occurrence:  _____________________   Time: _____________ am or pm?
7.	Date of discovery of the error:  ______________________ Time: _____________ am or pm?
8.	Did the medication occurrence happen over multiple consecutive administrations? Yes    No
9.	If yes in number 8, over what number of doses did the medication occurrence happen? ________
10.	Position of the person who gave the medication : (Check one)
	Direct Care 	 Supervisor	 Other
11.	Was the person who gave the medication MAP certified? Yes   No
12.	Please describe what happened: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
13.	MAP consultant’s title:  Registered Nurse   Registered Pharmacist   Health Care Provider
14.	Name of consultant contacted : ____________________________________________
15.	Date consultant contacted: _________________________ Time: __________________ am or pm?
16.	Was medical intervention recommended? Yes    No
17.	If yes in number 16, Check all that apply: 
 Lab work	 Other tests     Health Care Provider visit     Clinic visit
 Emergency room visit    Hospitalization
18.	Did any of the following situations or conditions result from the medication occurrence (Check all that apply)  Illness     Injury    Death
19.	Was DPH notified?  Yes     No
20.	Date DPH was notified: ___________________________ Time: ________________ am or pm?
21.	Was an Incident Report filed as a result of the medication occurrence?  Yes      No
22.	What has been done to prevent this from happening in the future? (training, review, change in systems, etc.) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
23.	What medications was the person supposed to get? 
Name of medication	Dosage	Frequency/Time	Route	

				
24.	What medications did the person get? (If medication was omitted, please write NONE)
Name of medication	Dosage	Frequency/Time	Route	

				
25.	Number of medications supposed to be given at the same time as the medication occurrence (include the medication(s) involved in the medication occurrence (check one)                                                                             1   2  3  4  5  6-10  11-15
26.	Was there a recent change in the medication order for the medication(s) involved in the MOR? Yes    No
27.	If yes in number 26, date of medication order change: _____________________________
28.	Can this medication occurrence be connected to a single staff person?  Yes   No If Yes, answer #29--33
29.	Who made the medication error? ____________________________________________________
30.	Status of the person who made the error:  Regular staff member   Temp. agency staff   FH Relief staff
31.	Does the person who made the error regularly give medications?    Yes    No
32.	Was the person who made the error working their regular shift?    Yes    No
33.	Was the person who made the error working at their routine site?    Yes    No