Incident Report
Type of incident:
HIPAA
Clinical
Non-Clinical
Human Resource
Sentinel
Incident Time:
Incident Date:
Incident Location
Person Involved:
Patient
Staff
Visitor/Watcher
Others
Type of Other Person Involved
SENTINEL EVENT: (specify)
Name of Person Involved:
Position:
Employee No.:
Department/Unit:
If Patient is Involved (Name):
MRN
Age/Gender:
IR #:
NHS-OVR
Classification of Reportable Incident (please tick the appropriate box)
Clinical Practice/Procedure
Clinical Procedure(s) not followed
Failure to assess patient response to prescribed therapy
No response to call
Wrong patient
Breach of patient privacy
Adverse Events
Refusal to deliver care
Delayed in care deliver
Others (specify):
Others (Clinical Practice/Procedure):
Medications
Drug
Allergic Reaction
Dose
Adverse Reactions
Time/frequency
Patient
Near miss
Route
Prescription
Others (specify):
Others (Medications):
IV RELATED
IV not Given
Extravasation
Phlebitis
Infiltration
Thrombosis
Cellulitis
Adverse Reaction
Others (specify):
Others (IV Related):
Staff/Employee
Infection control Issues
Infectious substance
Needle Stick/Prick
Vehicular Accidents
Fall
Not responding to call
No show on duty
Others (specify):
Others (Staff/Employee):
HR
Habitual Absentee
Consistent late
Misconduct/Misbehavior
Breach of confidentiality
Conflict of interest
Unprofessionalism
Transportation issue
Specific day sickness every (e.g every Friday sickness):
Others (specify):
Others (HR - Specific Day Sickness):
Others (HR):
Medical Records
Missing Files
Medical records Unavailable
No Medical Record Number
Policy not available
Late File
Wrong file
Results/Notes in wrong file
Others (specify)
Others (Medical Records):
Infection control
Not wearing PPE
Break in infection control protocol
Break in sterile technique
Needle stick injury
Blood/Body fluid Splashes
Exposure to infectious disese
Exposure to hazardous materials
Spill incident
Others Specify:
Others (Infection Control):
LABORATORY
Wrong patient /labelling
Incomplete labelling
Blood samples not collected
Lost specimen
Specimen integrity
Delayed in blood extraction
Delayed result
Analytical
Others (specify)
Others (Laboratory):
Patient/Family/Visitor/Watcher
Dissatisfaction
Hematoma
Refuses for hospitalization
Refuse to call 998
Food Hygiene
Interferes on clinical practice
Unauthorized watcher
Others (specify)
Others (Patient/Family/Visitor/Watcher):
Equipment/Supplies
Improper handling
Not available
Missing equipment
Failure/malfunction
Damage Equipment
Wrong Equipment
Improper Storage
Mechanical problem
Others (specify)
Others (Equipment Supplies):
Safety
Patient Fall
Found on the floor
Electric Shock
Physical assault
Others (specify)
Others (Safety):
Fire / Security
Fire/Smoke Incident
Water leak
Property Missing
Theft
Property Damage
Unathorized entry
Abduction
False alarm
Patient abuse by staff
Gas leak
Harassment (specify):
Others (specify):
Harassment
Others (Fire Security):
Behavioral
Assault
Verbal Aggression
Violent Behavior
Harassment
Suicide attempt
Others (specify)
Others (Behavioral):
Occupational
Disability
Exposure to hazards
Unconsiousness
Work Related illness
Others (specify)
Others (Occupational):
Description of Incident (Follow the When, Where, Who, What, Why and How when describing the incident):
Reported By:
Department/Position:
Email/Contact no.:
Date
Witness Account:
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