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Clinical Incident Reporting Form

This clinical incident report form is used to report any unexpected patient incidents related to care at facilities, including errors, safety hazards, injuries and sentinel events. It requests details of the incident such as location, those involved or affected, date/time, nature of the incident which may involve equipment, medication, procedures, outcomes, and contributing factors. The employee reporting the incident must acknowledge the accuracy of the reported facts, and the form is then reviewed by the Director of Credentialing at FASTAFF who may note any additional actions taken.

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Sooraj Thomas
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984 views2 pages

Clinical Incident Reporting Form

This clinical incident report form is used to report any unexpected patient incidents related to care at facilities, including errors, safety hazards, injuries and sentinel events. It requests details of the incident such as location, those involved or affected, date/time, nature of the incident which may involve equipment, medication, procedures, outcomes, and contributing factors. The employee reporting the incident must acknowledge the accuracy of the reported facts, and the form is then reviewed by the Director of Credentialing at FASTAFF who may note any additional actions taken.

Uploaded by

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

CLINICAL INCIDENT REPORT FORM

Use this form to report any unexpected patient incidents related to patient care or treatment, even if there is no
adverse patient outcome (this includes errors, safety hazards, injuries and sentinel events). This form is to be
completed by FASTAFF personnel in addition to any reporting requirements of the facility/hospital. After completion,
please return to FASTAFF by faxing to 888-928-3050.

Details of where incident was discovered


Identification of person affected by incident: Location:
Name: Hospital (include address):

Date of Birth: Department/Unit:

Date & Time of incident:

Onsite Staff involved


Name: Title:

Nature of incident [check appropriate box(es)]


Malfunction Equipment / Monitors Breach of Policies / Protocol Failure to perform investigation
Lack of Equipment / Monitors Poor patient preparation Delay in urgent investigation
User error of Equipment / Monitors Inappropriate request Failure to interpret results
Medication Prescription Error Inappropriate / no escort Wrong dose radiation
Medication Dispensing Error Breach in Confidentiality Wrong site
Medication Administration Error Patient documentation issue Wrong patient
Extravasation Patient positioning Repeat dose unnecessarily
Infection Control issue Consent Pregnancy not considered in
radiation exposure

Patient Outcome [check appropriate box(es)]


Death Pain / Prolonged pain Disruption to services
Critical condition Patient Distress Unable to assess outcome
Injury Delay in treatment Near miss by chance
Ill health Change to treatment Near miss by intervention
Temporary deterioration of condition Prolonged stay in hospital No adverse effect
Transfer to higher level of care Radiation over exposure

Contributory factors [check appropriate box(es)]


Knowledge & Training Poor communication Poor documentation
Staffing Issues Distraction Poor Handwriting
Lack of appropriate equipment Labelling Use of abbreviations / shorthand
Breach of Policy / procedure Supplies Storage
Other:
Summary of what happened: (please state facts only and not opinion – attach separate sheet if necessary)
Ensure that all necessary steps have been taken to support and treat anyone injured and prevent injury to others.
Ensure medical records are factual and up to date.

Action Taken as a Result of Incident: (please give brief details-attach separate sheet if necessary)

Employee Acknowledgment
Employee Name: Title/Position:

Acknowledgment - I acknowledge that the facts and circumstances reported above are true and accurate to the
best of my knowledge:

______________________________________________________
Employee Signature Date

INTERNAL USE ONLY – COMPLETED BY FASTAFF DIRECTOR OF CREDENTIALING

Action Taken as a Result of Incident: (please give brief details-attach separate sheet if necessary)

____________________________________________________________________
Director of Credentialing Date

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