Plastic Surgery Incident Report Template & Guidelines

Basic Information

• Date and Time of Incident: [//____] [: AM/PM]
• Location: □ OR □ Recovery Room □ Clinic □ Other: _______
• Patient Name: _________________
• Medical Record #: _____________

Incident Classification

Type of Event

• □ Adverse Event
• □ Near Miss
• □ Sentinel Event
• □ Equipment Malfunction
• □ Medication Error
• □ Other: _______

Severity Level

• □ Minor (No harm)
• □ Moderate (Temporary harm)
• □ Major (Permanent harm)
• □ Catastrophic (Death/severe permanent harm)

Incident Details

Description of Event

Immediate Actions Taken

Witnesses

Name: _________________ Role: _____________ Name: _________________ Role: _____________

Medical Details

Procedure Being Performed

Complications

□ Bleeding □ Infection □ Anesthesia-related □ Wrong-site surgery □ Other: _______

Follow-up Actions

Required Notifications

• □ Surgeon notified
• □ Department head notified
• □ Risk management notified
• □ Patient/family notified

Corrective Actions

Sign-off

Reported by: _________________ Title: _________________ Date: [//____]

Reviewed by: _________________ Title: _________________ Date: [//____]