Gastroenterology Practice Incident Report Form

Standardized Documentation Template for Adverse Events and Near Misses

Gastroenterology

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Last updated: Mar 24, 2025

Basic Information

  • Date and Time of Incident: //___ Time: : AM/PM
  • Location: □ Procedure Room □ Recovery □ Waiting Area □ Other: _______
  • Person Completing Report: ________________
  • Staff Members Involved: ________________

Incident Classification

□ Patient Safety Event □ Medication Error □ Equipment Malfunction □ Procedural Complication □ Infection Control Issue □ Other: ________________

Patient Information

  • Patient Name: ________________
  • Medical Record #: ________________
  • Date of Birth: //___
  • Procedure (if applicable): ________________

Incident Details

Description of Event



Immediate Actions Taken



Patient Outcome

□ No Harm □ Minor Harm □ Moderate Harm □ Severe Harm □ Death

Follow-up Actions

Notifications Made

□ Physician □ Administrator □ Risk Management □ Patient/Family □ Other: ________________

Preventive Measures



Sign-off

Completed by: ________________ Date: //___ Reviewed by: _________________ Date: //___

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