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Patient safety event:ID:Pt:^Event:Nom:AHRQ
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Date form completed
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{mm/dd/yyyy}
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Medication or substance involved:Type:Pt:^Patient:Nom:AHRQ
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Medication:Type:Pt:Medication:Nom:AHRQ
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Ingredients for compounded preparations:Find:Pt:Medication:Nom:
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Biological product:Type:Pt:Medication:Nom:AHRQ
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Lot # Vaccine
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Type of nutritional product:Type:Pt:^Patient:Nom:AHRQ
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Best characterization of medication or other substance event:Find:Pt:^Event:Nom:AHRQ
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Incorrect action:Type:Pt:^Patient:Nom:AHRQ
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Best description for the incorrect dose:Find:Pt:^Patient:Nom:AHRQ
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Best description for the incorrect timing:Find:Pt:^Patient:Ord:AHRQ
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Best description for the incorrect rate:Find:Pt:^Patient:Ord:AHRQ
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Best description for incorrect strength or concentration:Find:Pt:^Patient:Ord:AHRQ
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Expiration date:Date:Pt:Medication:Qn:AHRQ
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{mm/dd/yyyy}
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History of allergies or sensitivities to the medication or substance administered was documented:Find:Pt:^Patient:Ord:AHRQ
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Medication or substance contraindication - potential or actual interaction:Find:Pt:^Patient:Nom:AHRQ
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Stage in the process that the event originated, regardless of the stage at which it was discovered:Find:Pt:^Patient:Nom:AHRQ
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Medication or other substance details panel:-:Pt:Medication:-:AHRQ
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Intended route of administration:Find:Pt:^Patient:Nom:AHRQ
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Actual route of administration - attempted or completed:Find:Pt:^Patient:Nom:AHRQ
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Generic or investigational drug name:ID:Pt:Medication:Nom:
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Ingredient - RxNorm RXCUI:ID:Pt:Medication:Nom:
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Brand name:ID:Pt:Medication:Nom:
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Brand name - RxNorm RXCUI:ID:Pt:Medication:Nom:
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Manufacturer name:ID:Pt:Medication:Nom:
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Medication strength:Dosage:Pt:Medication:Qn:
?
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Clinical drug component - RxNorm RXCUI:ID:Pt:Medication:Nom:
?
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Dose form Medication
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Dose form RxNorm RXCUI Medication
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Medication or substance was prescribed:Find:Pt:^Patient:Ord:AHRQ
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Medication or substance was given:Find:Pt:^Patient:Ord:AHRQ
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