Pharmacy AI · Module 2 · Unit 4 · Practical 2

Pharmacovigilance Reporting Desk

Aim — To work a suspected adverse drug reaction from first report to submitted case — taking the history from the patient, classifying seriousness and expectedness, scoring causality, and filing a valid report inside the regulatory clock.

The call

The ward has telephoned the drug information centre about a patient who has developed a rash and is unwell. You are the pharmacovigilance pharmacist. Nothing has been established yet — the history is yours to take.

  1. You must interview the patient. Each question you choose to ask costs time; the answers determine everything that follows.
  2. Seriousness is a defined regulatory category based on outcome, not on how unpleasant the symptom is.
  3. Causality is scored with the Naranjo algorithm, which you complete question by question — the score is computed from your answers, not asserted.
  4. A serious, unexpected, suspected reaction starts a 24-hour reporting clock. The clock in this exercise is compressed.
  5. A report missing any of the four minimum elements is invalid and does not count as reported.

Not sure how any of that is actually done? The tab is the full reporting guide — what is reportable, the four minimum elements, the seriousness criteria, the form filled section by section, where it goes and by when. It stays available while you work the desk.

Assessment rubric

Assessment criteriaMarks
History taking — asking the questions that matter20
Seriousness classification15
Expectedness against the product information10
Naranjo causality assessment25
Valid report — all four minimum elements20
Immediate clinical action and follow-up10
Total100

Pass 50. Report validity and timeliness are reported separately.

Achievement badges

🗣 Good Historian⚖ Correct Classification 🧮 Causality Expert⏱ Within 24 Hours🏅 Valid Report

How to report — the student's guide

This section is the reference for the practical. It is how an adverse drug reaction is actually reported in India: what counts as reportable, the four elements without which a report does not exist, how each box on the form is filled, where the form goes and by when. Read it before you take the call, and keep it open while you work the desk.

The one rule that governs everything below: you report on suspicion, not proof. You are never required to establish that the medicine caused the reaction — only that you suspect it might have. Deciding causality is the assessor's job, and it is done after your report arrives, not before you send it.

Who reports, and to whom

Reporting in India runs through the Pharmacovigilance Programme of India (PvPI), launched in 2010, whose National Coordination Centre is the Indian Pharmacopoeia Commission (IPC) at Ghaziabad. Reports are collected by ADR Monitoring Centres (AMCs) — usually a hospital department, and in this exercise your own — which check and code each case before forwarding it to the NCC. The NCC assesses and collates the national data and uploads it to VigiBase, the WHO global database held by the Uppsala Monitoring Centre, so that a signal too rare to see in one country can emerge from the world's data. Regulatory action in India is taken by CDSCO on the NCC's recommendation.

Anyone may report. Doctors, pharmacists, nurses, dentists and other healthcare professionals report, and so may patients and their carers on the consumer form. You do not need seniority, permission, or a diagnosis to file a report.

Reporting is not an accusation. A report is a safety observation, not an admission of negligence, and it is not a complaint against the prescriber. The reporter's identity is held in confidence and the patient is identified only by initials. Fear of blame is the single largest cause of under-reporting — and under-reporting is how avoidable harm continues.

The eight steps

Decide that it is reportable — and lower your threshold

If you suspect a medicine has harmed a patient, it is reportable. Report it even when the reaction is well known, even when you think someone else will report it, and even when you are not sure the drug is responsible.

Report all of these:

  • Any suspected adverse reaction, whether or not it is listed in the product information
  • Reactions to over-the-counter, herbal, Ayurvedic, Unani, Siddha and homoeopathic products, and to self-medication
  • Harm arising from medication errors, overdose, misuse, abuse and off-label use
  • Lack of expected efficacy, particularly with antimicrobials, antiepileptics, anticoagulants, vaccines and contraceptives
  • Reactions in pregnancy and breastfeeding, and any suspected effect on the foetus or infant
  • Drug interactions, drug–food interactions, and withdrawal reactions
  • Suspected spurious, falsified or substandard medicines, and product quality problems
Why the threshold is low: pre-marketing trials enrol a few thousand patients for a few months. A reaction occurring in one patient in ten thousand cannot appear in them. Every such reaction that is ever discovered is discovered because somebody who was not certain reported anyway.

Secure the four minimum elements — without these there is no report

A case is valid only if all four are present. A form missing any one of them is not entered into the database and does not count as having been reported, however much other detail it contains.

1 · An identifiable patientInitials, age or date of birth, sex, or a hospital number. Enough to know this is one specific person and to recognise a duplicate. Never the full name.
2 · An identifiable reporterYour name, qualification and contact details — so the case can be followed up. Held in confidence.
3 · A suspect medicineAt least the name. Brand and batch matter greatly for quality problems and biologicals, but the name alone makes the report valid.
4 · A suspected reactionWhat happened to the patient, described in clinical terms, with the date it began.
Everything else on the form is desirable and improves the case — none of it is required for validity. The rule exists so that incomplete information is never a reason to stay silent: send the four, then follow up with the rest.

Classify seriousness — before you think about causality

Serious is a regulatory category defined by outcome, not a description of how unpleasant the reaction is. An agonising but self-limiting reaction is not serious; a symptomless finding that lands the patient in hospital is. Seriousness decides the reporting speed, so it is settled first and independently of whether the drug is to blame.

A reaction is serious if it:

  • Results in death
  • Is life-threatening — the patient was at risk of death at the time of the event
  • Requires inpatient hospitalisation, or prolongs an existing admission
  • Results in persistent or significant disability or incapacity
  • Causes a congenital anomaly or birth defect
  • Is another medically important event — one requiring intervention to prevent any of the above
Do not confuse serious with severe. Severity describes intensity — a severe headache. Seriousness describes consequence. A severe headache is not serious; a symptomless rise in INR to 9 is.

Establish expectedness against the product information

Expected means the reaction is already described in the approved reference safety information — the Summary of Product Characteristics or package insert. It does not mean common, mild or predictable. A rare and fatal reaction that is listed is expected; a trivial one that is not listed is unexpected.

Expectedness does not change whether you report. It changes the urgency, because a reaction that is serious and unexpected and suspected is the combination that triggers expedited reporting and is the most likely to represent a new signal.

Choose the right form and the right programme

Not every adverse event goes to PvPI on the ADR form. Sending a case to the wrong programme delays it and loses it.

What happenedWhere it goes
Suspected reaction to a medicine (allopathic, OTC, herbal, AYUSH), including errors and quality problemsPvPI — Suspected Adverse Drug Reaction Reporting Form, via your AMC
A patient or carer wishes to report themselvesPvPI — Medicines Side Effect Reporting Form (consumer version)
Adverse event following immunisation under the national programmeAEFI surveillance — AEFI reporting form to the district immunisation officer
Failure or injury caused by a medical device, implant or diagnostic kitMvPI — Materiovigilance Programme of India, also coordinated by IPC
Transfusion reaction to blood or a blood productHvPI — Haemovigilance Programme of India, NIB Noida
Serious adverse event in a patient enrolled in a clinical trialSponsor, Ethics Committee and CDSCO under the New Drugs and Clinical Trials Rules — not the spontaneous route
When a case could belong to two programmes — a device used to give a medicine, a reaction to a transfused product — report it to both rather than choosing. A duplicate is trivial to reconcile; a missed case is not.

Fill the form — section by section

The PvPI Suspected ADR Reporting Form runs in lettered sections. What each expects, and the mistake students most often make in it, is set out below. Write what you know; enter "not known" rather than leaving a box empty, so the assessor can tell the difference between missing information and information you have not yet sought.

SectionWhat you writeThe common mistake
A · Patient information
Initials, age or date of birth, sex, weight
Initials only, age at the time of the event, and weight where a dose calculation mattersWriting the full name — a confidentiality breach; or giving today's age rather than the age when it happened
B · Suspected reaction
Date started, date of recovery, description
What was observed, in clinical terms, with the date of onset and how it evolvedWriting a diagnosis you have assumed ("drug allergy") instead of describing what you actually saw
C · Suspect medicine(s)
Name, manufacturer, batch and expiry, dose, route, frequency, therapy dates, indication
Brand and generic name, the batch number from the pack, the dates therapy started and stopped, and why it was prescribedOmitting the batch number and the therapy start date — the two fields that make a quality investigation and a temporal assessment possible
Dechallenge
Did the reaction settle when the drug was stopped or reduced?
Yes, no, or not applicable / not known — including when the drug was stopped too recently to tellAnswering "no" when the drug was stopped yesterday. That is unknown, and recording it as "no" wrongly argues against the drug
Rechallenge
Did it reappear when the drug was given again?
Almost always not done — and correctly so, since deliberate rechallenge after a serious reaction is unethicalRecording "no" for a rechallenge that was never performed
Concomitant medicinesEverything else the patient takes, with dates — prescribed, OTC, herbal, AYUSH and supplementsListing only the prescription chart, so the interacting product is never seen
D · Other relevant historyAllergies, previous reactions, comorbidities, renal or hepatic impairment, pregnancy, smoking and alcoholLeaving it blank — this is where the alternative explanations live, and their absence is itself evidence
E · Seriousness and outcomeTick every seriousness criterion that applies, then the outcome: recovered, recovering, not recovered, recovered with sequelae, fatal, or unknownTicking "serious" on the strength of how distressing it was, rather than against the six defined outcomes
F · Reporter detailsName, profession, address with PIN, telephone and email, date and signatureLeaving contact details off — which makes follow-up impossible and costs the report its validity

Submit it — and know the clock you are working to

Hand the completed form to your ADR Monitoring Centre. Where there is no AMC, or the reporter is a patient, any of the national routes below may be used directly.

Your AMCThe normal route, and the fastest. The pharmacovigilance associate checks the form with you, codes the reaction and forwards it.
Toll-free helpline1800-180-3024 — for reporting by telephone and for advice on completing a form.
EmailScan or complete the form and send it to the NCC at the IPC.
ADR PvPI mobile appReport from the ward, with the form's fields on the phone.
OnlineThe reporting form on the IPC website. Confirm you are using the current version of the form before you submit.
Who is reportingBy when
Healthcare professional, spontaneous report to an AMCVoluntary and without a statutory deadline — but as soon as possible, and the same working day for a serious reaction, while the detail is still accurate and the batch still traceable
Investigator, serious adverse event in a clinical trialTo the sponsor, the Ethics Committee and CDSCO within 24 hours of becoming aware, with the detailed report following within 14 days
Marketing authorisation holder, serious unexpected reaction occurring in IndiaWithin 15 calendar days of first knowledge, to CDSCO
Marketing authorisation holder, periodic reportingPeriodic Safety Update Reports on the schedule set in the licensing rules
The clock in this practical is compressed. The desk gives you a 24-hour expedited window running at one simulated hour per second, because the case is a serious, suspected reaction. Treat it as the discipline the real timeline demands, not as the statutory deadline for a spontaneous report.

Follow it up — and act on the patient in front of you

A report is a beginning. Send the outstanding items as soon as you have them: the batch number, the outcome, laboratory and histology results, and what happened after withdrawal. Respond to the AMC when it queries the case.

Causality is assessed after submission, at the AMC and the NCC, using the WHO-UMC scale — certain, probable, possible, unlikely, conditional, unassessable — supported where appropriate by the Naranjo algorithm, which you use on the desk. A case scored unassessable is almost always one whose form was too thin to assess. That is within your control.

Filing the report is not the clinical intervention. Reporting protects future patients; this patient still needs the reaction recorded as an allergy in the record so the drug cannot be re-prescribed, needs to be told what to avoid — including drugs that cross-react — needs the referrals the reaction demands, and where appropriate an alert card. A perfectly completed form beside a chart that still lists the drug is a failed practical.

Before you submit — validity check

Tick what your report actually contains. The four marked required decide whether the case is valid at all; the rest decide how useful it is.

A completed specimen — the case you are about to work

This is the carbamazepine case from the desk, written up as it would be submitted. Dates are illustrative; note how little of it is speculation and how often "not known" appears where the answer genuinely is not known.

A · Patient information
Patient initials
D. S.
Age at time of event
62 years
Sex
Female
Weight
64 kg
B · Suspected adverse reaction
Date reaction started
10 days after starting therapy; febrile prodrome for 2 days before the eruption
Date of recovery
Not recovered at the time of reporting
Describe the reaction
Widespread maculopapular eruption beginning on the chest and spreading to the face, arms and back, progressing over 24 hours to blistering with skin detachment. Ulceration of the oral mucosa preventing swallowing, with conjunctival injection and discharge, and ulceration of the genital mucosa — three mucosal surfaces involved. Preceded by two days of fever and myalgia. Clinical picture consistent with Stevens–Johnson syndrome / toxic epidermal necrolysis.
C · Suspect medicine
Name (generic / brand)
Carbamazepine — brand and manufacturer as printed on the dispensed pack
Batch no. and expiry
To be taken from the pack and forwarded — requested from the ward
Dose, route, frequency
200 mg, oral, twice daily
Therapy dates
Started 10 days before onset; stopped the day before this report
Indication
Newly diagnosed seizure disorder
Dechallenge
Not known — the drug was withdrawn only yesterday and the eruption characteristically continues to evolve for several days after withdrawal
Rechallenge
Not done — rechallenge would be unethical in a suspected severe cutaneous adverse reaction
Concomitant medicines
Levothyroxine and omeprazole, both taken unchanged for several years. No OTC, herbal or AYUSH products reported.
D · Other relevant history
History
No previous drug reaction of any kind. No known allergies. No intercurrent infection identified. HLA-B*15:02 status not known — testing to be discussed.
E · Seriousness and outcome
Seriousness
Serious — life-threatening, and required hospitalisation
Outcome
Not recovered at the time of reporting
Expectedness
Expected — Stevens–Johnson syndrome is described in the approved product information as a rare reaction. Reported expeditiously nonetheless on grounds of seriousness.
Action taken
Carbamazepine withdrawn and recorded as an allergy in the record. Patient counselled that the aromatic anticonvulsants cross-react. Urgent dermatology and ophthalmology review requested. Alert card to be issued.
F · Reporter
Reporter
Name, qualification, department, hospital address with PIN, telephone, email, signature and date

Ten ways students lose a report

  1. Waiting until you are sure. Certainty about a rare reaction only ever arrives after enough reports have accumulated. Yours is one of them.
  2. Assuming somebody else has reported it. In practice nobody has. Duplicates are reconciled in minutes; silence is permanent.
  3. Not reporting because the reaction is already well known. Known reactions still need numbers — that is how frequency, risk factors and severity are established.
  4. Leaving off your contact details. The report becomes invalid and unfollowable at once.
  5. Writing the patient's full name. A confidentiality breach; initials with age and sex are all that is wanted.
  6. Recording "no" where the answer is "not known". Most often on dechallenge and rechallenge — and it systematically argues against the drug on evidence that does not exist.
  7. Omitting the batch number. Without it a quality defect cannot be traced to a batch, and a biological cannot be traced to a product.
  8. Recording a diagnosis instead of an observation. Write what you saw; the assessor draws the conclusion.
  9. Confusing severe with serious, and so reporting an intense but trivial reaction urgently while a symptomless dangerous one waits.
  10. Filing the form and stopping there — leaving the drug un-flagged in the record, where it will be prescribed again.

Take the call

Alizon Teaching Hospital · Drug Information Centre · ADR Monitoring Centre link

Case report & regulatory outcome

Complete the case to generate your report, then write and submit it below.