Internal Medicine Clinical Incident Report Form

Basic Information

• Date of Incident: //____
• Time of Incident: : □ AM □ PM
• Location: _________________
• Reporter Name & Role: _________________

Patient Information

• Patient Name: _________________
• DOB: //____
• Medical Record #: _________________

Incident Details

Type of Incident (check all that apply)

□ Medication Error □ Treatment/Procedure Complication □ Patient Fall □ Equipment Malfunction □ Laboratory/Diagnostic Error □ Communication Error □ Documentation Error □ Other: _________________

Severity Level

□ Near Miss (No Harm) □ Minor Harm □ Moderate Harm □ Severe Harm □ Death

Incident Description

Detailed account of what occurred:

Immediate Actions Taken

Witnesses

Name(s) and Role(s):

Follow-up

Notifications Made To:

□ Attending Physician □ Department Head □ Risk Management □ Patient Safety Officer □ Other: _________________

Root Cause Analysis Factors

□ Communication □ Training/Education □ Equipment/Technology □ Policies/Procedures □ Environmental □ Human Factors

Preventive Measures Recommended

Sign-off

Reported by: _________________ Date: //____ Reviewed by: _________________ Date: //____