Oral Surgery Incident Report Form Template

Patient Information

• Full Name: ________________
• Date of Birth: ____________
• Chart Number: ____________
• Date of Incident: _________
• Time of Incident: _________

Incident Details

Type of Incident (check all that apply)

• Surgical complication
• Wrong site/procedure
• Medication error
• Equipment failure
• Patient injury
• Infection control breach
• Other: ________________

Location of Incident

• Operating room
• Recovery area
• Consultation room
• Other: ________________

Description of Incident

Detailed account of what occurred: _______________________________

Immediate Actions Taken

Steps taken to address the situation: ____________________________

Staff Involved

Primary Provider

• Name: ________________
• Role: ________________
• Contact: ______________

Witnesses

• Names and roles: ________________________________________

Patient Outcome

• No harm
• Minor harm - no intervention required
• Moderate harm - intervention required
• Severe harm
• Other: ________________

Follow-up Actions

• Notification to patient/family: [ ] Yes [ ] No
• Incident reported to risk management: [ ] Yes [ ] No
• Documentation in patient record: [ ] Yes [ ] No

Preventive Measures

Steps to prevent recurrence: __________________________________

Authorization

Report completed by: Name: ________________ Signature: ____________ Date: ________________

Reviewed by: Name: ________________ Signature: ____________ Date: ________________