Dental Practice Incident Report Form

Basic Information

• Date of Incident: ________________
• Time of Incident: ________________
• Location in Practice: ________________
• Patient Name (if applicable): ________________
• Chart Number: ________________

Type of Incident (check all that apply)

□ Patient-related incident □ Staff injury □ Equipment malfunction □ Infection control breach □ Medication error □ Property damage □ Other: ________________

Incident Description

Detailed account of what occurred: ________________

Persons Involved

Staff Members Present

1. Name: ________________ Role: ________________
2. Name: ________________ Role: ________________

Witnesses

1. Name: ________________ Contact: ________________
2. Name: ________________ Contact: ________________

Immediate Actions Taken

Medical Intervention (if applicable)

• First aid administered: □ Yes □ No
• Treatment provided: ________________
• Referral made: □ Yes □ No
• If yes, to whom: ________________

Follow-up Actions

• Patient contacted: □ Yes □ No Date: ________________
• Risk management notified: □ Yes □ No
• Insurance carrier notified: □ Yes □ No

Prevention Plan

Steps to prevent future occurrences: ________________

Signatures

Reporting Staff Member: ________________ Date: ________________ Practice Manager: ________________ Date: ________________ Dentist: ________________ Date: ________________