1. Event Time & Location /Details (filed out by reporter): 2. Patient Information (Complete only if Incident): 3.

Incident): 3. What is being reported?

CONFIDENTIAL Date of the Even: / / Time of Incident: (AM, PM) Patient's Name……………………………………………………  Incident.  Reportable Event.
Event Location: Medical Record:  Sentinel Event.  Near Miss.
Reporting Department /Section: Date of Birth: / /  Unsafe Condition:
Responding Department /Section: Gender:  M /  F Any circumstance that increases the probability of a
Other Involved Departments:  Inpatient  Outpatient  Employee  Visitor  Other patient safety event.
4. Factual Description of the Event (filed out by reporter): 5. Report Date: 6. Treatment given (filed out by reporter):
Date: / /  Anonymous Reporter
Quality & Pt. Safety DEP. Reporter’s Name:………………………………………………
OCCURRENCE VARIANCE Mobile Number: …………………………………………………
REPORT (OVR) E-mail Address……… …………………………….……………
(Not part of Medical Record) Please tick the box if additional information attached. Reporter’s Position Title: ………………………………………
7. Injury occurred (Yes/ No), if yes please fill information (filled by the 8. To Be Completed by Person in Charge at Time of Incident:
9. Contributing Factors (to be filled out by the reporter
reporter direct manager/ person in charge): ▪ Other Departments/External Bodies Informed? direct manager/ person in charge) refer to Appendix F
Type of Injury:  Physical  Psychological  yes  no  NA (Chose top 3 only):
▪ Next of Kin/Relatives Informed?  yes  no  NA  Patient Factors.
Level of Harm: ▪ Patient Informed?  yes  no  NA  Task and Technology Factors
 Insignificant  Minor  Moderate  Major  Catastrophic ▪ Has risk assessment been undertaken/reviewed following this
 Individual (staff) Factors
incident (Risk Assessment Tool):  yes  no  NA  Team Factors
Likelihood Category: Name: ….………………………………………………………  Work Environmental Factors
 Rare  Unlikely  Unlikely  Likely  Almost Certain Professional Title………………… Badge Number: …………………  Organizational & Management Factors
For Medication Error only:  A  B  C  D  E  F  G  H  I  Signature: ……………………… Date: / /  Institutional Context Factors
10. Event Category (filed out by OVR Manager/Person responsible to 12. Incident Risk Classification & Rating (filled by the
11. Risk Management Unit (to be filled out by OVR Manager): reporter direct manager/ person in charge): for review
manage the OVR):
 1 .Infection Control Related Issues  16 .Behavior & approval by the OVR manager) Appendix D & E:
 2 .Occupational Health  17 .Staff related Issues ▪ Event Received in the Risk Unit within 24 ⃝ Yes ⃝ No
 3 .Housekeeping  18 .Patient Care Management hrs. of Discovery
 4 .Intravenous  19 .Laboratory Related Issues
 5 .Pressure Ulcer(Injury)  20 .Procedural ▪ Feedback Received with in Appropriate time ⃝ Yes ⃝ No
 6 .Skin Lesion Integrity  21 .Medical Equipment Issues (10 day) for Green and Yellow Risk Level
 7 .Medication  22 .Facility Maintenance
 8 .Communication Issues  23 .Environment / Safety
 9 .Falls  24 .Accommodation related Issues
▪ Feedback Sent to Reporting Department with ⃝ Yes ⃝ No
 10 .Radiation treatment (Ionizing radiation  25 .Information Technology two working days of receiving responding
Non-Ionizing (US, UV, MRI, Laser, other). Related Issues department feedback
 11 .Labor and Delivery related issues  26 .Medical Imaging and
 12 .Supply Chain issues (logistics) Diagnostic Procedures ▪ Incident Added to the Risk Register ⃝ Yes ⃝ No
 13 .Laundry services  27 .Food Service
 14 .Sentinel Events  28 .Clinical Nutrition ▪ OVR Closed
 15 .Security Related Issues  29. ID/Document/Consent
⃝ Yes ⃝ No
13. Outline Any Action Taken to Prevent 14. Feedback Review by the Reporter: 15. Feedback Review by the Reporter Direct
Recurrence (Immediate and planned follow up to Feedback Shared with me: (Yes/ No) Manager:
be filled by responding department). Feedback Satisfactory (Yes/ No) if no please write Feedback Shared with reporter: ( Yes/  No)
Name: ………………………………………………… your comments below: Feedback Satisfactory ( Yes/  No)
Professional Title: …………………………………… Reporters Name:……………………… ……………… • if no please write your comments below:
Badge Number: ……………………………………… Professional Title………… …………………………… Manager Name: .………………………………………
Signature: ………………………… Date: / / Badge Number: ……………………………………… Professional Title………………… ……………………
Signature: ………………………… Date: / / Badge Number: ………………………………………
Signature: ………………………… Date: / /

Comments: Comments:

Name: ….……………………………………………………… Professional Title…………………………………… Name: ….……………………………………………………… Professional Title……………………………………

Badge Number: ………………………… Signature: ………………………… Date: / / Badge Number: ………………………… Signature: ………………………… Date: / /

IPP-QPS-001 (02) Form 01 (OVR Form)