Hasil Sembuh Tidak Sembuh Disabiliti/Cacat Kematian Tidak Tahu
Obat PTEI Yang Digunakan Indikasi Rute Dosis Tanggal
Obat Lain Yang Digunakan indikasi
Pengobatan Lain Yang Digunakan
Radiasi Transfusi Darah Anestesi Lainnya Tanggal pengiriman : Tanggal diterima HO: Diterima oleh : ◦ Accidental drug intake by child ◦ ◦ Accidental exposure ◦ ◦ Accidental overdose ◦ ◦ Documented hypersensitivity to administered drug ◦ ◦ Drug administered at inappropriate site ◦ ◦ Drug administration error ◦ ◦ Drug dispensing error ◦ ◦ Drug dose omission ◦ ◦ Drug exposure via breast milk ◦ ◦ Drug label confusion ◦ ◦ Drug name confusion ◦ ◦ Drug prescribing error ◦ ◦ Expired drug administered ◦ ◦ Inappropriate schedule of drug administration ◦ ◦ Incorrect dose administered ◦ ◦ Incorrect drug administration duration ◦ ◦ Incorrect drug administration rate ◦ ◦ Incorrect drug dosage form administered ◦ ◦ Incorrect route of drug administration ◦ ◦ Incorrect storage of drug Intentional overdose Intercepted drug administration error Intercepted drug dispensing error Intercepted medication error Labelled drug-disease interaction medication error Labelled drug-drug interaction medication error Labelled drug-food interaction medication error Multiple drug overdose Multiple drug overdose accidental Multiple drug overdose intentional Overdose Poor quality drug administered Radiation exposure Radiation overdose Radiation underdose Underdose Vaccination error Wrong drug administered Wrong technique in drug usage process