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Incident Report: Patient Label

An incident report was filed describing an event involving a patient. The report notes the patient's name, date and location of the occurrence, and the time. The nature of the incident is classified and involves a fall by the patient. A narrative description provides factual details about how the incident happened. The department took immediate corrective action and the department head plans follow-up action. The report was received by quality assurance.

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Moumita
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494 views2 pages

Incident Report: Patient Label

An incident report was filed describing an event involving a patient. The report notes the patient's name, date and location of the occurrence, and the time. The nature of the incident is classified and involves a fall by the patient. A narrative description provides factual details about how the incident happened. The department took immediate corrective action and the department head plans follow-up action. The report was received by quality assurance.

Uploaded by

Moumita
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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INCIDENT REPORT

Note : Please ensure all fields are complete

Name of the party involved


(other than the patient) : _______________________________________________

Date of Occurrence : ___________________________________________________


Patient Label
Area where incident occurred : __________________________________________

Room / Bed No. __________________ Time of Occurrence : __________________

Incident occurred to : Classification of incident : Treating consultant :


Patient Staff Adverse event Sentinel event

Visitor Others Near Miss

Nature of incident (please tick)


Fall Laboratory sample related Radiology related
Patient Incorrect labelling I V contrast reaction
Staff Incorrect sample collection Incorrect patient for procedure
Visitor Sample lost Long waiting time
Others (specify) Others(specify)

Requisition / reports related Equipment related Administrative / documentation errors


Requisition errors Equipment malfunction Billing errors
Incorrect report Equipment accessories missing Order entry errors
Report delayed Damaged during transfer Software related errors
Report lost / unavailable Damaged during use Documentation errors
Despatching error Others(specify) Missing medical record
Others(specify) Others(specify)

Surgery / procedure related Clinical care related Medication related


Incorrect patient / site Bed Sores Prescription error
Swab / Instrument not accounted for Refusal of treatment Dispensing error
PAC not done Delay in care Drug reactions
Injury to patient during surgery Orders not / incorrectly carried out Administration delay
Material / consumable not available Care given by unauthorized person Administration error
Others(specify) Violation of patient privacy Non availability
Forceps injury to infant Incorrect storage
Injury to patient Incomplete / incorrect documentation
Others(specify) Contaminated / expired medication
Incorrect labelling
Others(specify)

Security related Needle stick injury Consent related


Assault to patient Injury to patient Incorrect consent form used
Assault to Staff Injury to staff Incomplete consent form
Assault to visitor Injury to Visitor Consent not taken
Theft Others(specify) Others(specify)
Absconding patient
Others(specify)

Others
RH/QLT/F/01
Narrative Description Of Occurrence
(Describe how incident happened. Be factual and specific. Do not assume. Use Separate Sheet Of Paper If Required

Immediate corrective action taken by department

Department Head Follow-up Action

Person Completing Form Received by (QA)

Name : Name :

Designation: Designation:

Signature : Date : Signature : Date :

Quality Assurance
For Information To : Comments
Yes No
QA Committee

Investigation Completed On:

_____________________________

Reviewed by Committee On:

_______________________________

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