PSO Healthcare Practitioner Medication and Vaccine Event Report

Please answer the questions as completely and accurately as possible. Your answers will help us to better understand the type of events that are happening, where and why they are happening, and how to help those people being affected. We will contact you if we have any questions after reviewing the report.

First Name *

Last Name *

Email *

Confirm Email *

Telephone Contact *

Event Type *

Select...

Please describe the event or hazardous condition *

Please provide as much detail about the event and associated process breakdowns as possible.

If this problem involves a specific medication or vaccine, please include the names and manufacturers of each product involved. We ask that you also include other pertinent information, including dosage form (e.g., capsule, tablet, injection), concentration or strength, and dose, that will help us to more fully analyze the issue and advocate for change.

Causes and Contributing Factors *Please tell us the reasons (e.g., causes, contributing factors) why this event happened.

Risk-reduction Strategies: *Please describe the strategies and/or process changes you put in place to prevent possible future events.

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