Family Medicine Clinical Incident Report Form

Patient Information

• Name: ________________
• DOB: _________________
• MRN: _________________
• Date of Incident: ________
• Time of Incident: ________

Incident Details

Type of Incident (check all that apply)

• Medication Error
• Patient Fall
• Treatment Delay
• Communication Error
• Equipment Malfunction
• Documentation Error
• Other: _______________

Incident Severity

• Near Miss (No Harm)
• Minor (No Treatment Required)
• Moderate (Treatment Required)
• Severe (Hospitalization Required)
• Critical (Life-threatening)

Location of Incident

• Exam Room
• Waiting Area
• Laboratory
• Front Desk
• Other: _______________

Incident Description

Detailed account of what occurred:

Immediate Actions Taken

Witnesses

Name(s) and role(s) of any witnesses:

Follow-up Actions

• Patient Notified
• Family Notified
• Documentation in EMR
• Risk Management Notified

Root Cause Analysis

Factors contributing to the incident:

Preventive Measures

Recommendations to prevent recurrence:

Report Completed By

Name: ___________________ Role: ___________________ Signature: _______________ Date: ___________________

Supervisor Review

Name: ___________________ Signature: _______________ Date: ___________________