Clinical Incident Report Sample – Fill Out and Use This PDF

A Clinical Incident Report Sample is a way to communicate the details of an adverse event that occurred at a health care facility.

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Clinical Incident Report Sample PDF Details

Clinical incident reports are written documents that describe an incident or event that occurred within a clinical setting. They are used to help improve patient care, and can be helpful in identifying system-wide issues. A clinical incident report sample can help you understand what information should be included in a clinical incident report. Included in this blog post is a link to a real world example of a clinical incident report, as well as an explanation of the information included in it. By understanding the purpose and content of a clinical incident report, you can ensure that your own reports are thoroughly documented and accurate.

The listing offers information about the clinical incident report sample. It is really worth making the effort to read this before starting filling in your form.

Question	Answer
Form Name	Clinical Incident Report Sample
Form Length	2 pages
Fillable?	Yes
Fillable fields	74
Avg. time to fill out	15 min 22 sec
Other names	clinical incident report, hospital incident report form, clinical incident form, clinical incident report form

12

Form Preview Example

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 of Birth:	Department/Unit:
	Date & Time of incident:
	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

How to Edit Clinical Incident Report Sample Online for Free

It won't be hard to complete clinical incident form using our PDF editor. This is how you may simply prepare your form.

Step 1: Search for the button "Get Form Here" on the site and select it.

Step 2: So you will be on your document edit page. It's possible to add, adjust, highlight, check, cross, add or erase fields or text.

These particular sections will help make up the PDF form:

entering details in clinical incident report step 1

Include the required data in the Patient Outcome check appropriate, Pain / Prolonged pain Patient, Contributory factors check, Poor communication Distraction, Disruption to services Unable to, and Poor documentation Poor segment.

clinical incident report Patient Outcome check appropriate, Pain / Prolonged pain Patient, Contributory factors check, Poor communication Distraction, Disruption to services Unable to, and Poor documentation Poor fields to fill

You'll be requested for particular fundamental data so that you can fill out the Summary of what happened: (please, and Employee Acknowledgment Employee section.

step 3 to filling out clinical incident report

Be sure to specify the rights and responsibilities of the sides within the Employee Acknowledgment Employee, Title, Position INTERNAL USE ONLY – COMPLETED BY, and Action Taken as a Result of box.

clinical incident report Employee Acknowledgment Employee, Title/Position:, INTERNAL USE ONLY – COMPLETED BY, and Action Taken as a Result of fields to complete

Finalize by reading the following fields and completing them accordingly: Action Taken as a Result of.

step 5 to finishing clinical incident report

Step 3: Once you've hit the Done button, your document is going to be accessible for export to each device or email address you indicate.

Step 4: You could make duplicates of the document toprevent different potential concerns. You need not worry, we do not disclose or track your details.

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