Quality Deviation

Quality Deviations
Country (*)aa
Province (*)aa
Quality Deviation Type (*)

Patient Data (*)

Last Name (*)aa
First Name (*)aa
Weight in Kg (*)aa
Age (*)aa
Gender (*)
What was the result of the deviation on the patient? (*)

Quality Deviation Description (*)

Description (*)aa

Relevant complementary tests (with date and result)

Descriptionaa
Was the medication with the deviation administered to the patient? (*)
Did the administration of the medication to the patient cause an adverse event? (*)

Which?

Description (*)aa

Underlying disease and relevant medical conditions (allergy, pregnancy week, alcohol, drugs, liver or kidney dysfunction, smoking, etc.)

Descriptionaa

Concomitant medication (including alternative therapies)

Descriptionaa
Medication with deviation
Generic Name (*)aa
Commercial Name (*)aa
Pharmaceutical Form (*)aa
Indication of Use (*)aa
Batch / Series Number (*)aa
Dosage and Route of Administration (*)aa
Expiration Date (*)aa
Sample Shipping
Do you have a sample of the product with the quality deviation? (*)
Amount of units sentaa
Date of detection of the deviation and/or event (*)aa
Date of this report (*)aa

Communicator Data (*)

Full Name (*)aa
Workplace (*)aa
Address (*)aa
Profession (*)aa
Phone (*)aa
Email (*)aa
Fields marked with (*) are required.The information provided will be strictly confidential.

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