DEPARTMENT OF DEVELOPMENTAL SERVICES LICENSED NURSE MEDICATION ADMINISTRATION ERRORPROHIBITED

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Certified Non-licensed Staff Medication Administration Error/ Prohibited Practice Tracking Form

Department of Developmental Services

Licensed Nurse Medication Administration Error/Prohibited Practice Tracking Form

RN/LPN:______________________________________________ Primary Worksite:__________________________

All errors or prohibited practices (PP) require retraining by the Supervising RN.
All errors or prohibited practices committed by the same person will be treated as one occurrence until retraining occurs
The Supervising RN shall record the number of errors/ prohibited practices committed in that occurrence BUT will only assign one point value for the occurrence.
The assigned point value of the occurrence will be determined by the highest class of error or prohibited practice committed (e.g. Ten Class “A” prohibited practices and one Class “B” error will be assigned a value of 2 points- the value of the Class B error only.) See box below. The total number of points for all occurrences will be recorded in pencil in the box at the bottom of the form. At the time of each entry, point totals shall be reviewed and adjusted to reflect the addition or expiration of points. Points expire after 180 days.
The total tracking point value only applies to the determination of the level of offense reached as a result of the occurrence. The level of offense indicates the recommended sanction action as specified in Medication Sanctions for Licensed Nurses and the responsible person.
This tracking form shall be permanently maintained as documentation of a pattern of errors. A copy should be shared when nurses change primary work site within the region.

Class A medication errors/ PP: 1^st, 2^nd, 3^rd, 4^th occurrence = 0.5 tracking points assigned for each occurrence;

5^thoccurrence and beyond= 2 tracking points assigned

Class B medication errors/ PP: 2 tracking points assigned for each occurrence
Class C medication errors/PP : 25 tracking points assigned for each occurrence

Date o f occurrence:

Location:

#Class A

errors/PP

#Class B

errors/ PP

# Class C

errors/ PP

Points for occurrence

Retraining date

Date of expiration of points

_ DEPARTMENT OF DEVELOPMENTAL SERVICES LICENSED NURSE MEDICATION ADMINISTRATION ERRORPROHIBITED __________________________________RN Current Total: Keep current total in pencil I.D.PR.015 Attachment B- Medication Administration Sanctions Licensed Nurses 11-10

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