Flood Runaway (only report if client is missing more than 4 □ □ hrs) Others: __________________________________ Emergency Services Involved: (choose all the apply) Ambulance/paramedics Law Enforcement □ □ Crisis Outreach Warden Services □ □ ER Services No Emergency Services Involved □ □ Fire Department Other _________________________ □ Death of a client Summary of event: Summary of known details. Report death of client even if death occurs outside of the provision of services. Illness Suspected abuse/neglect? □ □ Completed suicide □ □Homicide Death due to: Accident Other: ________________________ □ Medication Errors Type: Reason: Medication Administration error □ □ Omission Supply exhausted □ □ Wrong dose administered forgot □ □ Wrong method of administration Prescription unfilled □ □ Wrong time (>1 hr variance) Incorrect chart entry □ □ Other: ______________________________ Forgot to send with client □ Not administered during home visit □ Administered name: Name of drugs: Treatment location: ED □ Treatment requested as result of error? Yes or No Outpatient □ Emergency intervention on site □ Prescriber contacted? Yes or No Date prescriber contacted:
□ Flood □ Runaway (only report if client is missing more than 4 hrs) Others: __________________________________ Emergency Services Involved: (choose all the apply) □ Ambulance/paramedics □ Crisis Outreach □ ER Services □ Fire Department □ Law Enforcement □ Warden Services □ No Emergency Services Involved Other _________________________ Death of a client Summary of event: Summary of known details. Report death of client even if death occurs outside of the provision of services. Death due to: □ Illness □ Completed suicide □ Accident □ Suspected abuse/neglect? □Homicide Other: ________________________ Medication Errors Type: □ Medication □ Omission □ Wrong dose administered □ Wrong method of administration □ Wrong time (>1 hr variance) Other: ______________________________ Reason: □ Administration error □ Supply exhausted □ forgot □ Prescription unfilled □ Incorrect chart entry □ Forgot to send with client □ Not administered during home visit Administered name: Name of drugs: Treatment requested as result of error? Yes or No Treatment location: □ ED □ Outpatient □ Emergency intervention on site Prescriber contacted? Yes or No Date prescriber contacted:
OCFS%20Reportable%20Events%20Form%209-18.docx