General Surgery Incident Report Form Template

Patient Information

• Patient Name: ________________
• MRN: ________________
• DOB: ________________
• Date of Incident: ________________
• Time of Incident: ________________
• Location: ________________

Incident Type (Check all that apply)

• Wrong Site/Side/Patient
• Retained Surgical Item
• Equipment Malfunction
• Medication Error
• Sterility Breach
• Anesthesia-related
• Unexpected Bleeding
• Other: ________________

Personnel Present

• Attending Surgeon: ________________
• Assisting Surgeon: ________________
• Scrub Nurse: ________________
• Circulating Nurse: ________________
• Anesthesiologist: ________________

Incident Description

Detailed account of the event: ________________

Immediate Actions Taken

Patient Outcome

• No Harm
• Minor Harm
• Moderate Harm
• Severe Harm
• Death

Contributing Factors

• Communication Issues
• Protocol Deviation
• Equipment/Supply Issues
• Environmental Factors
• Staffing Issues
• Other: ________________

Follow-up Actions Required

Report Completed By

• Name: ________________
• Title: ________________
• Date: ________________
• Signature: ________________

Department Head Review

• Name: ________________
• Date: ________________
• Signature: ________________