CIRCL test platform Incident Report Form Date of Incident Type of Incident — Select Type — Near Miss Medication Incident Other Who discovered the incident? Prescription Filling Step Involved — Select Step — Transcribing Rx Error Medication Selection Error Count Error Pack Check Error(Non-registrant) Final Check Error(Registrant) Medication(s) Involved Degree of Harm to the Patient No Harm Mild / Temporary Harm Moderate / Prolonged Harm Severe / Permanent Harm Death Incident Description & How it was Discovered Contributing Factors Submit Incident Report
