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    Incident Report: Patient Label

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    Moumita
    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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    Incident Report: Patient Label

    Uploaded by

    Moumita
    122 views2 pages
    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.

    Original Description:

    Reporting of incidence at hospital.

    Original Title

    1 Incident Report

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    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.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    122 views2 pages

    Incident Report: Patient Label

    Uploaded by

    Moumita
    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.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    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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