Step-by-Step Guide to Write and Report Medication Errors Under NDIS (2025 Update)
Learn how to record, write, and report medication errors under NDIS. Includes examples, reporting rules, templates, and a full step-by-step guide for providers.
Medication errors can happen in any disability support setting, from missed doses to wrong medications. Under the National Disability Insurance Scheme (NDIS), providers must record, manage, and report medication errors to ensure safety, transparency, and compliance with NDIS Commission rules.
This 2025 guide explains:
- What counts as a medication error
- Which errors must be reported
- When they are NOT reportable
- How to write a compliant NDIS medication error report (step-by-step)
- Common causes and prevention
- Submission process (PDF + software)
- Free downloadable template
What is a Medication Error Under NDIS?
A medication error under the NDIS is any preventable mistake in prescribing, dispensing, preparing, or administering medication that could lead to harm, actual harm, or poses a risk to a participant’s health, wellbeing, or dignity.
The NDIS Commission considers a medication error a serious incident when it results in significant harm, requires medical intervention, or indicates a failure in a provider’s duty of care. Even if no harm occurs, the error must still be recorded and addressed within your incident management system.
Medication errors can happen during:
- Medication preparation
- Administration
- Documentation
- Storage and handling
- Handover between shifts
- Communication with pharmacists or prescribers
Understanding what counts as an error helps providers maintain compliance, improve safety, and prevent repeated incidents.
Types of Medication Errors (NDIS Examples Included)
Below are the most common medication errors that providers must record and manage, along with examples to make each type clear:
1. Wrong medication
Giving a participant a medication that was not prescribed to them.
Example: Administering another participant’s antipsychotic medication due to packaging confusion.
2. Wrong dose
Providing more or less than the prescribed amount.
Example: Giving 500 mg instead of 250 mg.
3. Wrong participant
Administering medication to the wrong person due to similar names or poor verification processes.
Example: Two participants with similar initials received mixed-up medication packs.
4. Wrong time
Giving medication too early, too late, or missing the scheduled administration window.
Example: A 7 PM dose given at 11 PM, affecting medication effectiveness.
5. Missed medication
Failing to give a required dose.
Example: Forgetting a morning insulin dose during a busy shift.
6. Unauthorised medication administration
Giving medication without the proper consent, training, or authorization.
Example: Administering PRN medication without documenting the behaviour or seeking supervisor approval.
7. Documentation errors
Incomplete, incorrect, or missing documentation related to medication administration.
Example: Marking a dose as given when it wasn’t, or forgetting to sign the MAR chart.
8. Wrong route
Providing medication through the wrong method.
Example: Giving a medication orally instead of via inhalation.
9. Duplicate dose
Accidentally giving the same dose twice within a short period.
Example: A shift change leads to two staff members unknowingly giving the same morning dose.
10. Medication storage or labelling errors
Incorrect storage, mixing up similar-looking packaging, or failing to label medications properly.
Example: Leaving medications unrefrigerated affects potency.
When is a Medication Error Reportable to the NDIS Commission?
Under the NDIS Commission’s rules, providers must report certain types of incidents that occur during the delivery of support and services. Some medication errors may fall into the category of a reportable incident if they cause harm or have the potential to cause serious harm.
The following medication errors should be reported to the NDIS Commission:
- Errors that result in serious injury or hospitalisation.
For example, if a participant is given the wrong medication and requires emergency medical treatment. - Errors that cause significant health risks, even if no harm occurs.
This may include a situation where the wrong medication was administered, but prompt medical attention prevented harm. - Repeated medication errors that indicate a pattern or systemic issue.
If a provider notices the same type of error occurring multiple times, it must be escalated and reported. - Errors linked to neglect or improper care.
Failing to administer a prescribed medication on multiple occasions may be considered neglect and therefore reportable. - Medication errors that involve the use of restrictive practices.
If medication is administered as a chemical restraint without proper authorisation, this must be reported as a serious incident.
By reporting these incidents, providers demonstrate compliance with NDIS requirements and reinforce their commitment to participant safety.
When is a Medication Error NOT Reportable?
Not all medication errors require reporting to the NDIS Commission. Some incidents require only internal documentation.
Medication error is not reportable if:
- The timing was slightly off with no risk (e.g., 5–10 minutes late).
- A participant refuses medication, but the refusal is documented and followed up on.
- Documentation error corrected immediately with the correct dose given.
- The wrong medication was prepared but caught before administration (near miss).
- Pharmacy label error discovered before use.
These should still be recorded internally to support audits and quality improvement.
How to Write an NDIS Medication Error Report
Writing a medication error report involves more than describing what happened. It must be clear, factual, and structured. Below is a step-by-step process:
Step 1: Record the basic details
Include the participant’s name, the staff member or members involved, the date, time, and location of the incident.
Step 2: Describe what happened
Explain the type of error. Was it the wrong medication, wrong dose, missed dose, wrong person, or duplicate dose?
Step 3: Identify how the error was discovered
State who noticed the error and how it was identified. For example, it may have been discovered during a double-check or by a pharmacist.
Step 4: Document immediate actions
List the steps taken right away. This might include notifying a doctor, providing first aid, or monitoring the participant.
Step 5: Classify the error
Indicate whether it was a near miss, a Category D error, or another type of error.
Step 6: Record contributing factors
Note possible reasons, such as unclear instructions, human error, system breakdown, or environmental distractions.
Step 7: Suggest preventive measures
Document how the error can be avoided in the future. This may include better training, clearer communication, or implementing a double-check process.
Step 8: State the outcome for the participant
Explain whether the participant was unharmed, required monitoring, or needed medical intervention.
Example: Medication Error Incident Report Sample
The following is a sample of how a nurse might write a medication error incident report:
On 12 September 2025, at 9:15 AM, Nurse Sarah prepared 500 mg of Paracetamol instead of the prescribed 250 mg. Before administration, another staff member identified the error. The error was classified as a near miss (Category C). No harm was caused. Immediate corrective action included reviewing prescription labels and reinforcing dosage check protocols. Preventive measures: double-check the system before medication administration.
This format helps you provide clear, factual, and compliant information.
How to Submit Your Medication Report in NDIS
Submitting a medication error report involves both internal documentation and, in some cases, external reporting to the NDIS Commission. Here’s a simple, compliant process for providers:
1. Record the Incident Internally
All medication errors - including near misses, must be documented in your organisation’s incident management system (paper form or software such as Imploy)
Include key details: what happened, who was involved, medication name/dose, and immediate actions.
2. Notify Key People
Inform the participant (or representative), the on-call manager, and the prescribing doctor or pharmacist if needed. Clear communication is essential for safety and follow-up care.
3. Check if the Error Is Reportable
If the error caused harm, required urgent medical treatment, involved neglect, or relates to unauthorised chemical restraint, it must be reported to the NDIS Commission.
Minor timing errors, corrected documentation, or near misses are not reportable but must still be recorded internally.
4. Submit to the NDIS Commission (If Required)
For reportable incidents:
- Log in to the NDIS Commission Portal
- Complete the Reportable Incident Form
- Upload supporting documents (MAR chart, internal report, medical notes)
Serious incidents must be submitted within 24 hours, with follow-up details provided within 5 business days.
5. File and Review
Save submission receipts, file the report in the participant’s record, and complete a post-incident review. Update training or procedures if improvements are needed.
Legal & Regulatory Requirements under the NDIS
The NDIS Commission requires all registered providers to have an incident management system in place. Medication errors may be considered reportable incidents depending on the level of harm caused.
Key points to note:
- Report within required timeframes (usually 24 hours for serious incidents).
- Include all relevant details to demonstrate compliance and participant safety.
- Follow the “six rights” of medication administration: right person, right drug, right dose, right route, right time, and right documentation.
Components of a Good Medication Error Report
An effective NDIS medication error report should include certain key details.
- Basic details: Start by documenting the participant’s name, identifiers, staff involved, provider details, date, time, and location.
- Medication information: Record the name of the medication, the prescribed dose, route, frequency, and the prescribing doctor.
- Type and classification of error: Clearly describe the error, such as a wrong dose, a missed dose, the wrong medication, or an error with the person, route, time, or administration.
- Discovery: State how the error was identified and who identified it.
- Immediate actions taken: Document the immediate actions carried out, such as providing first aid, notifying a doctor, monitoring, withholding further medication, or informing the participant’s family.
- Impact and outcome: Record whether the participant was harmed, monitored, or unaffected.
- Contributing factors and root cause: Note any contributing factors, such as human error, system breakdown, unclear communication, or environmental influences. Include findings from any investigation.
- Follow-up and prevention: Record the follow-up steps, such as reporting to the NDIS Commission (if required), introducing preventive measures, staff training, policy or procedure changes, sign-off, and attaching any supporting documents if relevant.
Tips & Best Practices for Writing & Avoiding Errors
- Write objectively and stick to observed facts.
- Use simple, clear language to avoid jargon.
- Report immediately, don’t delay submissions.
- Fostering a non-blame culture encourages reporting without fear.
Conclusion + Free Template
An NDIS medication error report is not just a compliance requirement but a safeguard for participants and providers. Clear, accurate, and timely reporting ensures transparency, accountability, and ongoing improvement within disability services. Whether it involves a near miss or a Category D incident, reporting medication errors correctly is essential for supporting NDIS participants with dignity and safety.
To make reporting easier, download our Free NDIS Medication Error Report Template here. This simple tool helps providers record incidents in a clear, structured, and compliant way.
