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Request Type* Product QualityAdverse Drug ReactionsMedication Error
Is Drug Effective YesNo
Trade Name, Strength —Please choose an option—Acalabrutinib BOS, 100 mgAccofil, 300 µg /0.5 mLAccofil, 480 µg / 0.5 mLAcidoxax, 4 mgAllbloc, 1 mg/mLAnidulafungin, BOS, 100 mgApeto, 100 mgApeto, 15 mgApixaban BOS, 2.5 mgApixaban BOS, 5 mgAzithromycin BOS, 500 mgBatipan, 100 mg per 50 mLBatipan, 50 mgBimtoprost BOS, 0.1 mg/mLBirato, 250 mgBortezomib BOS, 3.5 mgBusulfan BOS, 6 mg/mLCabozantinib BOS, 20 mgCabozantinib BOS, 40 mgCabozantinib BOS, 60 mgCitarox, 1000 mgCitarox, 200mgCopsfin, 50 mgCopsfin, 70 mgDaptomycin BOS, 350 mgDemexa, 100 µ/mLDocadex, 20 mg/mLDocadex, 80 mg/4 mLEmcap, 500 mgEnoxaparin BOS, 20 mg/mLEnoxaparin BOS, 40 mg/mLEnoxaparin BOS, 60 mg/mLEnoxaparin BOS, 80 mg/mLEverolimus BOS, 5 mgEverolimus BOS, 10 mgEvonanz, 18 mg per 3 mLFenido, 257 mgFenido, 801 mgFerasiro, 180 mgFerasiro, 360 mgFerasiro, 90 mgFomepizole BOS 1 g/mLFoscarnet BOS, 24 mg/mLGemcitabine BOS, 1000 mgHemabo, 24 mg/1.2 mLHulio, 40 mgKetorolac BOS, 30 mg/mLLenalidomide BOS, 10 mgLenalidomide BOS, 15 mgLenalidomide BOS, 25 mgLenalidomide BOS, 5 mgLenvatinib TBM, 10 mgLenvatinib TBM, 4 mgLevetiracetam BOS, 100 mg/mLMilrinone BOS, 1 mg/mLNepexto, 50 mg/mLNepexto, 25 mg/mLOselow, 75 mgPelgraz, 6 mg in 0.6 mLPemitax, 500 mgPomalidomide BOS, 1 mgPomalidomide BOS, 2 mgPomalidomide BOS, 3 mgPomalidomide BOS, 4 mgRocuronium Bromide BOS, 10 mg/mLSermitor, 60 mgSorafenib BOS, 200 mgTecana, 20 mg/mLTeriflunomide BOS, 14 mgTigacycline BOS, 50 mgTranexamic acid BOS, 100 mg/mLTrumavar, 15/6.14 mgTrumavar, 20/8.19 mgTyenne, 162 mg per 0.9 mLTyenne, 200 mg per 10 mLTyenne, 400 mg per 20 mLTyenne, 80 mg per 4 mLTykodas, 100 mgTykodas, 50 mgTykodas, 70 mgVasopressin BOS, 20 U/mLVoriole, 200 mgXatiza, 60 mg / 1.5 mLXorola, 2.5 mgZelyssa, 18 mg per 3 mLZercepac, 150 mg
Dosage Form —Please choose an option—Solution for InjectionFilm-Coated TabletPowder for SolutionConcentrate for SolutionPowder for Concentrate for SolutionCapsuleSolution for InfusionTabletPre-filled syringePre-filled pen
Generic Name
Registration Number
Batch Number
Manufacturing Date
Expiration Date
Is this report to inform about similarity between medication names, products, inappropriate, or missing and misleading information in packaging and labeling AND did not result in a medication error YesNo
The incident related to product Namepackaging /labelingBoth
How did you obtain the medication From the pharmacy with a prescriptionFrom the pharmacy without a prescriptionFrom other stores (not a pharmacy)
Name and address of the store or pharmacy from which the medication was dispensed
Purpose of Use
Gender MaleFemale
Description
Attached File (PDF,IMG)
SUSPECTED DRUGS INFO (OPTIONAL)
Suspected Drugs —Please choose an option—Abiraterone acetate, 250 mgAnidulafungin, 100 mgBortezomib, 3.5 mgCapecitabine, 500 mgCaspofungin Acetate, 50 mgCaspofungin Acetate, 70 mgClofarabin, 1 mg/mLDaptomycin, 350 mgDasatinib, 100 mgDasatinib, 50 mgDasatinib, 70 mgDeferasirox, 180 mgDeferasirox, 360 mgDeferasirox, 90 mgDexmedetomidine, 0.1 mg/mLDocetaxel, 20 mg/mLDocetaxel, 80 mg/mLEnoxaparin, 20 mgEnoxaparin, 40 mgEnoxaparin, 60 mgEnoxaparin, 80 mgFosaprepitant dimeglumine, 150 mgFoscarnet, 24 mg/mLGemcitabine RTU, 1000 mgGemcitabine, 1000 mgGemcitabine, 200 mgIrinotecan, 20 mg/mLKetorolac, 30 mg/mLLetrozole, 2.5 mgLevetiracetam, 100 mg/mLMilrinone, 1 mg/mLOseltamivir, 75 mgOxaliplatin, 100 mgOxaliplatin, 50 mgPemetrexed, 500 mgPlerixafor, 24 mg/mLRocuronium, 10 mg /mLTigacycline, 50 mg/vialToremifene, 60 mgTranexamic acid, 100 mg/mLZoledronic Acid, 4 mg
Start Date End Date Purpose of Use
PATIENT INFORMATION (OPTIONAL)
Full Name Date Of Birth Height (cm) Weight (kg)
PRODUCT DETAILS (OPTIONAL)
How did you obtain the medication —Please choose an option—From the pharmacy with a prescriptionFrom the pharmacy without a prescriptionFrom other stores (not a pharmacy)
Name and address of the store or pharmacy from which the medication was dispensed Purpose of Use Strength Start Date Did you stop using the medication? YesNo
SIDE EFFECT (OPTIONAL)
Date of Event Started
Seriousness of ADR —Please choose an option—DiedLife ThreateningPermanent DisabilityHospitalizationProlonged Hospitalization More Than 24 HrCongenital AnomalyRequired Intervention to Prevent Permanent Impairment / DamageOther
Date of Event Ended Did you inform the doctor or pharmacist of these adverse event? YesNoUnknownIf Yes, Did he/she file an adverse event reporting form? YesNoUnknownCan we obtain further information from your treating physician YesNoIf yes, please provide us with the communication information of the treating physician
CONCOMITANT DRUGS (OPTIONAL)
Trade Name Strength Start Date End Date Purpose of Use
CONTACT INFORMATION (OPTIONAL)
Full Name
Occupation —Please choose an option—PhysicianPharmacistLawyerOther Health Care ProfessionalNurseConsumerOther
Patient Relation Email Mobile
