Cardiac Surgery Incident Report Form Template

Patient Information

• Patient Name: ________________
• Medical Record #: ____________
• Date of Birth: _______________
• Procedure Date: _____________

Incident Details

Time and Location

• Date of Incident: _____________
• Time of Incident: _____________
• Location: □ OR □ ICU □ Step-down Unit □ Other: _______

Type of Event (check all that apply)

□ Wrong Site/Side/Patient □ Equipment Malfunction □ Medication Error □ Sterility Breach □ Unexpected Bleeding □ CPB-related Incident □ Airway Management Issue □ Other: ________________

Severity Classification

□ Near Miss □ No Harm □ Mild Harm □ Moderate Harm □ Severe Harm □ Death

Event Description

Detailed account of the incident:

Immediate Actions Taken

Staff Involved

• Primary Surgeon: ______________
• Assisting Surgeon: ____________
• Anesthesiologist: _____________
• Perfusionist: ________________
• OR Nurses: __________________

Follow-up Actions

□ Patient/Family Notified □ Risk Management Notified □ Root Cause Analysis Required □ M&M Conference Review

Preventive Measures

Recommendations to prevent recurrence:

Report Completion

• Reporter Name: _______________
• Position: ____________________
• Date: _______________________
• Signature: ___________________

Form ID: CS-IR-[YYYY]-[###]