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    Pharmacist Drug Interactions Reporting Form by Dr.S.Balamurugan PharmD

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    balamurugan
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    Pharmacist Drug Interactions Reporting Form by Dr.S.Balamurugan PharmD

    Uploaded by

    balamurugan
    1K views2 pages
    Thank you for the report form. I will review it and get back to you.

    Original Description:

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    Original Title

    Pharmacist Drug Interactions reporting form by Dr.S.Balamurugan PharmD

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    Thank you for the report form. I will review it and get back to you.

    Copyright:

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    Download as docx, pdf, or txt
    1K views2 pages

    Pharmacist Drug Interactions Reporting Form by Dr.S.Balamurugan PharmD

    Uploaded by

    balamurugan
    Thank you for the report form. I will review it and get back to you.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    DRUG INTERACTIONS (DIs) REPORT FORM

    1. Date of event: Type of facility: *Government/Private location of event:

    Time of event: Hospital Clinic Pharmacy Ward A&E Clinic Pharmacy

    Others: Others:

    2. Describe interaction or problem 3.In which Process did the interaction occur?

    Drug-drug interactions

    Drug – Food interactions

    Drug – Beverage interactions

    Drug – Lab Test interactions

    Drug – Infusion fluid interactions

    Drug – Disease interactions

    Drug – Host interactions

    Drug – Parasite interactions

    Drug – Echochemical interactions:

    Others (Please specify):………………

    4. Did the interaction reach the Yes 5.Seriousness of the interaction

    Patient? No Death (dd/mm/yyy)------ Congenital anomaly

    6. Outcomes Life threatening required intervention

    Fatal Recovering Hospitalization-initial to prevent permanent

    Unknown Continuing or prolonged impairment/damage

    Recovered Other (specify) Disability others………………

    7. Indicate the possible interaction(s) and contributing factor(s)

    Multiple drug therapy Multiple prescribers Multiple pharmacological effect of drug

    Multiple diseases/predisposing illness Poor patient compliance Advancing age of patient

    Drug-related factors Others (Please specify):………………………..

    8.If available, please provide patients particulars(Don’t provide any identifiers)

    Age: Years/months Gender: Male Female Diagnosis: ----------------------------------


    9. Please complete the following for the product(s)involved. If more space is needed for additional products, kindly attach a
    separate page.

    S.No Drug name #1 Drug name #2 Clinical impact

    10. Reports are most useful when relevant materials such as 11.Suggest any recommendation, or describe polices or
    product label,copy of prescription/oreder.etc.,can be reviewed procedure you instituted or plane to institute to prevent
    can these materials be provided? Future similar interactions. If available, kindly attach
    investigational reports e.g., Root Cause Analysis(RCA)
    No

    Yes, Please specify

    --------------------------------------------------------------------
    --------------------------------------------------------------------

    Reporter- Please tick as appropriate: Doctor Pharmacist Dentist Nurse Other:............................

    Name:

    Address: Signature:………………………………..

    Phone:…………………………...Date:………….

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