Endocrinology Clinical Incident Report Template

Patient Information

• Patient Name: ________________
• DOB: //____
• MRN: ________________
• Date of Incident: //____
• Time of Incident: : AM/PM

Incident Classification

• Medication Error
• Equipment Malfunction
• Protocol Deviation
• Patient Fall
• Treatment Complication
• Laboratory Error
• Other: ________________

Specific to Endocrinology

• Insulin Administration Error
• Glucose Monitoring Device Malfunction
• Thyroid Medication Error
• Hormone Therapy Complication
• Adrenal Crisis Event
• DKA Management Issue

Incident Description

Provide detailed account of the incident:

Immediate Actions Taken

Patient Outcome

• No Harm
• Minor Harm - Required Monitoring
• Moderate Harm - Required Intervention
• Severe Harm - Required Extended Care
• Death

Contributing Factors

• Communication Issue
• Staff Training/Knowledge
• Equipment/Technology
• Policy/Procedure Gap
• Environmental Factors
• Other: ________________

Follow-up Actions Required

• Patient/Family Notification
• Physician Notification
• Quality Review Meeting
• Protocol Revision
• Staff Training
• Equipment Service

Report Completed By

Name: ________________ Role: ________________ Signature: ________________ Date: //____

Supervisor Review

Name: ________________ Signature: ________________ Date: //____