Periodontal Practice Incident Report Form

Patient Information

• Patient Name: ________________
• Date of Birth: ________________
• Chart Number: ________________
• Date of Incident: ________________
• Time of Incident: ________________

Incident Details

Type of Incident (check all that apply)

• Patient Safety Event
• Medication Error
• Equipment Malfunction
• Procedural Complication
• Infection Control Breach
• Patient Fall
• Other: ________________

Location of Incident

• Treatment Room
• Waiting Area
• Sterilization Area
• Other: ________________

Incident Description

Provide detailed account of what occurred:

Immediate Actions Taken

Staff Involved

• Primary Staff Member: ________________
• Witnesses: ________________
• Supervising Periodontist: ________________

Follow-up Actions

• Patient Notified
• Family Notified
• Incident Documented in Patient Chart
• Equipment Quarantined (if applicable)
• Risk Management Notified

Corrective Actions Planned

Sign-off

• Report Completed By: ________________
• Date: ________________
• Reviewed By: ________________
• Date: ________________

Submit completed form to Practice Manager within 24 hours of incident