Submit a Drug Incident Report (DIR)

• Facility information
  • Facility name
  • Address
  • MAP MCSR number
    • To locate, check for the MAP MCSR certificate posted in the medication storage room
• Facility type
• Date of loss
• Specific location of loss (unit, floor, etc., if applicable)
• Incident type
  • Diversion
  • Loss
  • Theft
  • Tampering
  • Documentation
  • Other (please specify)
• Drug information (use extra sheets if needed)
  • Name
  • Quantity
  • Strength
  • Dosage Form
• An explanation of what happened
  • Include factors may have contributed to loss
  • Include any other relevant information
  • State if patient harm was involved
  • Use extra sheets if necessary

The submission of the DIR form will satisfy DCP's requirements for both a telephonic and written report (the latter is currently required within 7 days of discovery).