Colorectal Surgery Critical Incident Report Form

1. Incident Information

Date of Incident: //_____ Time: : Location: □ OR □ Recovery □ Ward □ Other: _____________

2. Patient Information

Medical Record Number: ________________ Procedure Type: □ Elective □ Emergency ASA Classification: □ I □ II □ III □ IV □ V □ E

3. Event Classification

Type of Event

• □ Near Miss
• □ Adverse Event
• □ Sentinel Event

Phase of Care

• □ Pre-operative
• □ Intra-operative
• □ Post-operative
• □ Post-discharge

4. Event Details

Nature of Incident

• □ Wrong Site/Side/Patient
• □ Equipment Malfunction
• □ Medication Error
• □ Anastomotic Complication
• □ Surgical Site Infection
• □ Bleeding Complication
• □ Other: _____________

Severity Grade

• □ Grade I (No deviation from normal course)
• □ Grade II (Minor deviation)
• □ Grade III (Significant deviation requiring intervention)
• □ Grade IV (Life-threatening)
• □ Grade V (Death)

5. Immediate Actions Taken

Description: _____________________________ Staff Members Involved: ___________________

6. Contributing Factors

• □ Communication Issues
• □ Equipment/Technical Issues
• □ Protocol Deviation
• □ Staff Factors
• □ Patient Factors
• □ Environmental Factors

7. Follow-up Actions

Preventive Measures: _____________________ Quality Improvement Plans: ________________

8. Reporting Information

Report Completed By: _____________________ Position: _______________________________ Date: //_____

Supervisor Review: _______________________ Date: //_____