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.

QuestionAnswer
Form NameClinical Incident Report Sample
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesclinical 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 Sample Online for Free

It won't be hard to complete fillable ocddwss pf 09 002 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, 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 segment.

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

You'll be requested for particular fundamental data so that you can fill out the Ensure that all necessary steps, Action Taken as a Result of, Employee Acknowledgment, Employee Name, and TitlePosition section.

step 3 to filling out clinical incident report

Be sure to specify the rights and responsibilities of the sides within the Acknowledgment I acknowledge that, Employee Signature Date, INTERNAL USE ONLY COMPLETED BY, Action Taken as a Result of, and Director of Credentialing Date box.

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

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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