Vascular Surgery Incident Report Form Template

Patient Information

• Patient Name: ________________
• Medical Record Number: ________________
• Date of Birth: ________________
• Date of Incident: ________________
• Time of Incident: ________________

Incident Location

• Operating Room
• Vascular Lab
• Recovery Area
• Patient Room
• Other: ________________

Type of Incident

Procedural

• Wrong Site/Side
• Equipment Failure
• Bleeding Complication
• Thrombotic Event
• Access Site Complication

Medication-Related

• Incorrect Anticoagulation
• Contrast Reaction
• Medication Error
• Adverse Drug Reaction

Severity Classification

• Near Miss
• No Harm
• Mild Harm
• Moderate Harm
• Severe Harm
• Death

Immediate Actions Taken

Contributing Factors

• Communication Issue
• Equipment/Device Related
• Protocol Deviation
• Staff Training Issue
• System/Process Issue

Notifications Made

• Attending Surgeon
• Department Head
• Risk Management
• Patient Safety Officer

Follow-up Actions Required

Report Completed By

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

Reviewer Comments