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SECTION 1 - Completion to be performed by nurses or pharmacists with information gathered from the patient’s medical record, prescription, talking with the patient/caregiver and the care team. Section to be completed for ALL patients evaluated. |
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Patient record number:
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Sector (unit) in which the patient is hospitalized at the time of the evaluation:
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1.1 Sex
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( ) Female ( ) Male ( ) Other |
1.2 Age
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( ) Less than 18 ( ) 18-24 ( ) 25-44
( ) 45-59 ( ) 60-79 ( ) 80 or more |
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1.3 Are there any reports of drug allergies described in the patient’s chart? (including no known allergies)
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( ) Yes
( ) No |
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1.4 Was medication reconciliation1 performed by the pharmacist within the first 24 hours of the patient’s admission to this sector?
1 Obtaining a complete and accurate list of the patient’s usual medication use and then comparing it with the prescription at all transitions of care.
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( ) Yes
( ) No
( ) No - The patient is still within the 24-hour period at the time of evaluation |
1.5 How many drugs are prescribed for the patient in the current prescription?
Exclude “as needed”, “at the physician’s discretion” medications, attack doses, oxygen, dietary supplements, parenteral and enteral nutrition. Different doses of the same medication count as one medication.
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( ) 0
( ) 1 to 4
( ) 5 to 9
( ) 10 to 15
( ) 16 to 20
( ) More than 20 |
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1.6a Check below which medications are prescribed for the patient: 1.6b If any of these prescribed medications have not been administered in the last 24 hours, check the reason (if so, check more than one reason):
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Reasons for omission
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| Way not availabe |
Patient refuseed |
Absence of medication reconciliation |
Medication
unavailable |
Valid clinical justification |
Patient absent at the moment of administration |
Motive not identified |
Others |
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Anticoagulant |
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Opioids |
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Insulin |
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Anti-infectives (antibiotics, antifungals, antivirals, and antimalarials) |
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Any other prescribed medications |
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1.7 Has the patient received any of the following medications in the last 24 hours?
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( ) Anticoagulants: heparin, low molecular weight heparin, warfarin, and direct oral anticoagulants (dabigatran, apixaban, rivaroxaban) |
( ) Opioids |
| ( ) Intravenous or subcutaneous sedatives: midazolam, diazepam, propofol, fentanyl |
( ) Insulin |
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If the answer is YES to question 1.7, proceed to Section 2. If the answer is NO, then you have finished filling out this form.
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SECTION 2 - Only complete Section 2 if the patient has received any of the following medications: anticoagulant, opioid, intravenous or subcutaneous sedative, and/or insulin in the past 24 hours, as answered in question 1.7. Only answer questions related to the medication(s) received by the patient. The information can be collected by nurses or pharmacists. |
2.1 Anticoagulants (heparin, low molecular weight heparin, warfarin, and direct oral anticoagulants)
Signal of Damage Investigation: |
Did the patient present any kind of damage?
( ) Yes, bleeding
( ) Yes, venous thromboembolism ( ) No |
Has the patient received administration of vitamin K, protamine, or clotting factors?
( ) Yes ( ) No |
Does the patient have an International Normalized Ratio (INR) greater than 6 or an Activated Partial Thromboplastin Time (APTT) greater than 40 seconds?
( ) Yes, INR greater than 6
( ) Yes, APTT greater than 40 seconds ( ) No |
2.2 Opioids
Signal of Damage Investigation: |
Has the patient received naloxone administration?
( ) Yes
( ) No |
Is the patient’s respiratory rate below 8 breaths per minute (rpm)?
( ) Yes ( ) No |
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2.3 Injectable sedatives (midazolam, diazepam, propofol, fentanyl) Signal of Damage Investigation: |
Did the patient receive administration of the reversal agent flumazenil?
( ) Yes
( ) No |
Did the patient have common complications related to excessive sedation that included hypotension, delirium, respiratory depression, reduced Glasgow scale?
( ) Yes ( ) No |
2.4 Insulin
Signal of Damage Investigation: |
Does the patient have capillary blood glucose (< 70 mg/dL) or symptoms of hypoglycemia (anxiety, confusion, extreme hunger, fatigue, irritability, sweating, clammy skin, or hand tremors)?
( ) Yes, capillary blood glucose < 70 mg/dL
( ) Yes, symptoms of hypoglycemia
( ) No |
Is the patient in diabetic ketoacidosis (DKA - a serious complication of diabetes that occurs when the body produces too many ketones) or hyperglycemic hyperosmolar state (HSS - a situation of severe hyperglycemia, increased plasma osmolality, and dehydration)?
( ) Yes, diabetic ketoacidosis
( ) Yes, hyperglycemic hyperosmolar state
( ) No |
Did the patient receive administration of a reversal agent for hypoglycemia (glucose 10%-50% or intravenous glucagon 1 mg)?
( ) Yes
( ) No |
| If one of the answers was YES in Section 2, indicating a sign of harm, discuss the issue in an inter-professional meeting and decide on the level of harm, based on the World Health Organization’s International Classification of Patient Safety. This meeting should include (at least) one nurse, one pharmacist and one physician. |
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SECTION 3 - Inter-professional meeting |
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Definitions of harm according to the International Classification of Patient Safety
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No damage
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When the patient has no symptoms and needs no intervention. |
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Light damage
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Patient had mild symptoms, minimal or intermediate short-term damage without intervention or with minimal intervention (little treatment or observation). |
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Moderate damage
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Patient required intervention (e.g., supplemental procedure or additional therapy), prolonged hospitalization, loss of function, permanent or long-term damage. |
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Severe damage
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Patient required life-saving intervention, major medical/surgical intervention or major permanent or long-term damage, fetal disturbance/risk or congenital anomaly. |
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Death
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When the adverse event causes patient death. |
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Interprofessional meeting - Professionals involved
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1. Name: Role: Involved in patient care? Y/N
2. Name: Role: Involved in patient care? Y/N
3. Name: Role: Involved in patient care? Y/N
4. Name: Role: Involved in patient care? Y/N
5. Name: Role: Involved in patient care? Y/N |
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Based on the outcome of the inter-professional meeting, describe the level of harm identified.
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Anticoagulants √
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Learning after the inter-professional discussion: |
| No damage |
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| Light damage |
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| Moderate Damage |
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| Severe Damage |
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| Death |
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Opioids √
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Learning after the inter-professional discussion: |
| No damage |
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| Light damage |
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| Moderate Damage |
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| Severe Damage |
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| Death |
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Injectable sedatives √
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Learning after the inter-professional discussion: |
| No damage |
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| Light damage |
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| Moderate Damage |
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| Severe Damage |
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| Death |
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Insulin √
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Learning after the inter-professional discussion: |
| No damage |
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| Light damage |
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| Moderate Damage |
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| Severe Damage |
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| Death |
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Outcome of the inter-professional meeting:
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( ) Referral to the Superior Inter-professional Team meeting
( ) Incident Report Finalized Incident Report No. (if applicable) |
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General remarks:
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