Pharmacoeconomics and Safe Medication Use

Appendix 1. Adverse Drug Event Reporting Form

1. NAME

2. PATIENT ID #

3. LOCATION

4. AGE

5. SEX

6. REACTION ONSET DATE

7. DATE OF REPORT

8. DESCRIBE REACTION AND ITS MANAGEMENT. (Continue on the back if necessary. Use Arial Narrow

Font Size 10)

9. Check all appropriate

10. Did event abate after discon-

tinuing the drug?

11. Was patient’s electronic

allergy/ADE profile updated?

(If no, please explain on second page)

12. RELEVANT TESTS/LABORATORY DATA

SUSPECTED DRUG(S) INFORMATION

13. SUSPECTED DRUG(S) Give manufacturer & lot number for vaccine/ biologics/

biotechnological

17. DATES OF ADMINISTRATION

14. DOSE AND FREQUENCY

15. ROUTE OF ADMINISTRATION

18. DURATION OF ADMINISTRATION

16. INDICATION(S) FOR USE

19. CONCOMITANT DRUGS AND DATES OF ADMINISTRATION (Exclude those used to treat the reaction)

20. OTHER RELEVANT HISTORY (e.g., diagnoses, medical history, allergies, pregnancy)

INITIAL REPORTER (In confidence)

JCAHO Standard PI. 2.20 states that all serious adverse drug reactions are intensely analyzed.

Standard MM. 6.20 maintains that the responsible individual complies with internal and external

reporting requirements for adverse drug reactions. (2006 Comprehensive Accreditation Manual

for Hospitals)

Please take the time to complete this form for each suspected adverse drug reaction, and

forward it to the Department of Pharmacy for reporting at the next Adverse Drug Reaction

Subcommittee meeting.

Submission of a report does not necessarily constitute an admission that the drug caused the reaction

NAME AND ADDRESS OF REPORTER (Including

zip code)

TELEPHONE NO. (Include area code)

THE MANUFACTURER?

Patient died

Reaction treated with drug

Resulted in or prolonged

inpatient hospitalization

None of the above

YES

NO

MAYBE

YES

NO

ADE#:

Date

Time

MD Notified about Possible ADR

Pharmacist’s Signature

YES

NO