Pediatric Practice Incident Report Form

Basic Information

• Date of Incident: //___
• Time of Incident: : AM/PM
• Location: □ Exam Room □ Waiting Area □ Lab □ Other: _______
• Patient Name: _________________
• Date of Birth: //___
• Medical Record #: _____________

Incident Type

□ Medication Error □ Patient Fall □ Treatment Complication □ Equipment Malfunction □ Security Incident □ Communication Error □ Other: _________________

Incident Description

What Happened

Provide detailed description: ________________________

Contributing Factors

□ Staff Shortage □ Equipment Issues □ Communication Breakdown □ Protocol Deviation □ Environmental Factors □ Other: _________________

Immediate Actions Taken

• Medical Intervention Required? □ Yes □ No
• If Yes, Describe: _______________________________
• Parent/Guardian Notified? □ Yes □ No
• Time of Notification: : AM/PM

Staff Involved

Name(s) and Role(s):

1. _________________ Role: _________________
2. _________________ Role: _________________

Follow-up Actions

□ Incident Review Meeting Required □ Policy Review/Update Needed □ Staff Training Required □ Equipment Service Needed □ Other: _________________

Report Completed By

Name: _________________ Role: _________________ Signature: _________________ Date: //___

Supervisor Review

Name: _________________ Signature: _________________ Date: //___