[Visiting Pharmacist Services] Medication Incident/Near Miss/Clinical Cases Reporting Form
Please be reminded that, due to PATIENT PRIVACY, patients personal information MUST NOT be included in the report.
Report Section
For MI/Near Miss, please include following details:

-Date of MI/ near miss
-Date of discovery
-How the incident was discovered, what happened, and any immediate actions taken
-Medication involved
-Patient outcome

For clinical cases, the unusual points may be described.

Details of incident *
Photos of relevant documents/evidences (please HIDE patient identity)
Reporter
Name of reporter *
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