Oncology Incident Report Form Template

Patient Information

• Patient Name: ________________
• Medical Record Number: ________________
• Date of Birth: ________________
• Primary Oncologist: ________________

Incident Details

• Date of Incident: ________________
• Time of Incident: ________________
• Location: ________________

Type of Incident (check all that apply)

• Medication Error
• Chemotherapy Administration Issue
• Equipment Malfunction
• Patient Fall
• Treatment Protocol Deviation
• Radiation Therapy Incident
• Adverse Drug Reaction
• Other: ________________

Description of Incident

Detailed account of what occurred: ________________

Immediate Actions Taken

1. Initial response: ________________
2. Patient status/outcome: ________________
3. Notifications made: ________________

Contributing Factors

• Communication Issue
• Equipment/Technology
• Environmental Factors
• Human Error
• Policy/Procedure Issue
• Other: ________________

Patient Outcome

• Severity Level (1-5): ________________
• Required Interventions: ________________
• Follow-up Care Plan: ________________

Staff Involved

Name(s) and Role(s): ________________

Witness Information

Name(s) and Contact: ________________

Prevention/Corrective Actions

Proposed measures to prevent recurrence: ________________

Report Completed By

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

Supervisor Review

• Name: ________________
• Date Reviewed: ________________
• Comments: ________________
• Signature: ________________