Clinical Incident Report Sample PDF Details

The main purpose of a patient incident report is to guarantee that each incident, even if it appears minor, is documented systematically and uniformly. This method enables healthcare organizations to monitor patterns, recognize potential safety hazards beforehand, and enforce preventive actions.

Our patient incident report template is created to collect necessary information about unforeseen adverse events. This organized documentation aids in thorough incident analysis and promotes enhancements for any incident reporting system in a healthcare setting. Here is a summary of the main elements of this form:

- Patient and incident details. The form begins by capturing basic patient information such as name, date of birth, and specific hospital locations. It also details the exact date and time of the incident.

- Nature of the incident. A checklist that categorizes the incident type, such as equipment malfunction, medical error, or breach of confidentiality.

- Onsite staff involved. Names and titles of individuals involved, ensuring accountability and aiding in the investigation process.

- Patient outcome. Options to describe the immediate impact on the patient range from no adverse effect to more severe consequences like injury or critical condition.

- Contributory factors. A checklist identifying possible contributing factors, such as staffing issues, lack of equipment, or policy breaches, helps understand the underlying causes.

- Action taken. This is a space to describe the immediate actions taken following the incident. It is important to document responsive measures and corrective actions.

The form concludes with sections for a summary of objective facts of the incident, ensuring that all descriptions are factual and the reporting employee acknowledges the accuracy of the information provided.

Why Use Medical Incident Report Template?

Using a medical incident report form is crucial for healthcare facilities seeking to improve patient safety and manage incidents efficiently. A standardized template guarantees that all essential details are recorded with precision. 

This form simplifies the incident reporting process by providing predefined fields that guide the reporter through capturing all relevant details. This consistency also makes it easier for healthcare professionals to train staff to report incidents, ensuring nothing important is overlooked.

Moreover, standardized information allows for quicker and more effective data analysis. When every report follows the same format, hospital administrators can more easily identify trends, commonalities, and risk areas, leading to faster implementation of corrective measures. Using resolved patient incident reports greatly improves the readiness of healthcare personnel to handle any similar incidents in future situations.

A standard hospital incident report form helps communicate all information about incidents within the team or with external bodies. Also, many healthcare regulations require precise documentation of incidents for legal action. A patient incident report form helps ensure compliance by including all legally necessary fields, reducing the risk of penalties or legal issues from insufficient documentation.

QuestionAnswer
Form Name Clinical Incident Report Form
Form Length 2 pages
Fillable? Yes
Fillable fields 75
Avg. time to fill out 10 min
Other names clinical incident, incident report format in hospital, clinical incident report, hospital incident report sample

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 & 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 Form Online for Free

Using our PDF editor to complete a clinical incident report provides a convenient and efficient way to manage documentation for patient care issues.

If you work in healthcare or an administrative role, ensuring this document is accurately completed is critical for compliance, quality control, and ongoing training needs.

1. Enter Patient Identification Details

Input the patient's name, location within the hospital, date of birth, and any other identifying details requested in the form.

2. Document the Incident Specifics

Record the department or unit where the incident occurred and the precise date and time. Accurate timing can be crucial for subsequent reviews or legal considerations.

3. Describe the Nature of the Incident

Check the appropriate boxes that describe the nature of the incident. The form includes options such as equipment malfunctions, medication errors, and breaches of confidentiality.

4. Note Onsite Staff and Witnesses

List the names and titles of any staff members involved in or witnesses to the incident. This information is essential for follow-up interviews and determining the incident's scope.

 

entering details in clinical incident report step 1

5. Indicate the Patient Outcome

Specify the outcome for the patient using the checkboxes provided, such as injury, critical condition, or no adverse effect. Understanding the immediate impact on safety for the patient helps assess the incident's severity.

clinical incident report Patient Outcome check appropriate, Death Critical condition Injury, Pain Prolonged pain Patient, Contributory factors check, Disruption to services Unable to, Knowledge Training Staffing, Poor communication Distraction, and Poor documentation Poor fields to fill

6. Identify Contributory Factors

Identify and check off all events leading to the incident, like staffing issues or equipment lack. Recognizing these factors helps to implement preventive measures.

7. Provide a Summary of the Incident

Provide a clear and factual summary of what happened during the incident. Attach additional sheets if necessary to ensure a comprehensive written account.

step 3 to filling out clinical incident report

8. Detail Actions Taken

Document any immediate actions taken in response to the incident to address and mitigate its effects. It could include medical treatments provided, additional supervision, or other corrective actions.

9. Employee Acknowledgment

As the reporting individual, fill in your name and position and sign off on the report to acknowledge that the information recorded is accurate.

clinical incident report Acknowledgment I acknowledge that, Employee Signature Date, INTERNAL USE ONLY COMPLETED BY, Action Taken as a Result of, and Director of Credentialing Date fields to complete

10. Submit the Report

Once completed, the form should be submitted according to your healthcare facility's protocol, including faxing or uploading through a secure incident reporting system.

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