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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: _____________________________________________________________________

__________________________________________________________________________________________

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.)