Orthopedic Practice Incident Report Form

Patient Information

• Patient Name: ________________
• Date of Birth: ________________
• Medical Record #: ________________
• Contact Information: ________________

Incident Details

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

Type of Incident (check all that apply)

• Patient Fall
• Equipment Malfunction
• Medication Error
• Procedure Complication
• Wrong Site/Side
• Infection Control Issue
• Other: ________________

Description of Incident

Provide detailed account of what occurred:

Immediate Actions Taken

1. Initial Response:

2. Medical Interventions Required:

Witness Information

• Name(s): ________________
• Role(s): ________________
• Contact Information: ________________

Equipment/Devices Involved

• Device Name/Type: ________________
• Serial Number: ________________
• Condition: ________________

Follow-up Actions

• Patient Notification
• Family Notification
• Risk Management Notified
• Equipment Sequestered
• Photos Taken
• Additional Documentation Attached

Root Cause Analysis

Identify contributing factors:

Preventive Measures

Recommendations to prevent recurrence:

Report Completed By

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

Supervisor Review

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