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Medication Patient Safety Checklist
When too much, not enough, or the wrong medication is taken, poor results occur. Medications that
react with other drugs, vitamins, food, or herbs can also cause bad results. Discuss your medication
use with your doctor or pharmacist. To prepare for this discussion, complete the list below.
Name: ____________________________________________________________________________________
Drug and Food Allergies: _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Medication Name Dosage
(amount)
Times/Day
Medication
is taken
How
Medication
is taken
Why Medication
is taken
How Medication
is stored
Over the Counter Medications
Dietary or Herbal supplement
Medications that make you feel bad Description of the bad feeling
1.
2.
3.
1.
2.
3.
Review Dates: ____________________________:____________________________:____________________________
(The checklist should be reviewed at well exams, whenever a medication change occurs or when you have questions.)
To review your online HAP Pharmacy Claim History click on hap.org then go to OnlineServices
Approved //
HAP’s Hospital Quality and Patient Safety Committee D /
330498D.indd 1 3/22/10 9:47:01 AM