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Incident Reporting Checklist

The document is an incidence report checklist designed for healthcare settings, detailing the necessary information to be collected following an incident involving injury. It includes sections for documenting the date, time, location, individuals involved, type of incident, and required actions taken. The report must be completed accurately and submitted promptly to the appropriate authority, with signatures from all relevant parties.

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Hager Shaheen
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46 views3 pages

Incident Reporting Checklist

The document is an incidence report checklist designed for healthcare settings, detailing the necessary information to be collected following an incident involving injury. It includes sections for documenting the date, time, location, individuals involved, type of incident, and required actions taken. The report must be completed accurately and submitted promptly to the appropriate authority, with signatures from all relevant parties.

Uploaded by

Hager Shaheen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Incidence Report Check list

Student name: Hospital : Unit:


Date: Time: Group:
Items Score Done Not Comment
done
1. Fill date of incident 1
2. Fill time of the incident
2 (AM/ PM). 1
3. Fill place of the work3 (unit) /its phone number 1
4. Fill name and position of responsible person 1
who reported incident (head nurse / witness).
5. Fill who was injured 4 person 1
(patient/visitors/nursing staff /employee).
6. Fill the name of injured
5 person. 1
7. Fill age/ gender of injured person. 1
8. Fill the phone number 6 of injured person. 1
9. Fill type of incident7 1
10. Fill diagnosis (in case
8 if patient ) 1
11. Describe details of the incident objectively. 1
12. Fill name and position9 of involved personnel. 1
13. Fill name and position0 of witness. 1
14. Fill the comments of3 involved person 1
15. Fill the required intervention/action
5 taken (first 1
aid/hospital/police/others).
16. Fill other notes or comments
6 1
17. Fill repot to quality 8assurance unit 1
18. Notes on follow up 9action ,contact with 1
involved person.
19. Fill out the report completely, clear, accurately, 1
and based on facts.
20. After completing the incident report, all parties 1
must sign with ink, includes:
- Person who reported incident sign /fill
position or title/ date of report.
- The witness
- Supervisor who received it (in case call
others).
Total 20
NB
1- The incident report is submitted as soon as possible to the appropriate
authority (supervisor/quality assurance).
2- No nurse is blamed in an incident report.
3- Follow specific documentation guidelines.
4. The report form should not be copied or placed in the client’s record.

1
Incident Report Format

➢ Date of incident :
➢ Time of incident: AM: PM:
➢ place of the work (unit) / its phone number :

➢ Name and position of responsible person who reported incident (head nurse /
witness):

➢ Who was injured person patient Visitors


Nursing staff Employee

➢ Name of injured person:


➢ Age of injured person:
➢ Gender of injured person:
➢ phone number of injured person:
➢ Type of incident
❑ injuries
❑ Patient fall.
❑ Patient complaints.
❑ Medication errors
❑ Equipment failure.
❑ A visitor who exhibits symptoms of a communicable disease.

➢ Patient diagnosis (in case if patient ):

➢ Describe details of the incident objectively (how did the accident happen-what
caused the accident):

➢ Name and position of involved personnel:


Name: Position:

2
➢ Name and position of witness:

Name: Position:

➢ Comments of involved person:

➢ The required intervention/action taken

First aid Hospital Police


Others (please specify: )

Description:

➢ Other notes or comments:

➢ Report to quality assurance unit :


Name: Phone number:

➢ Notes on follow up action, contact with involved person:

➢ Signature of person who reported incident: position/title:


➢ Date of report:

➢ Witness signature:

➢ Supervisor signature if submit the report to other authority as police /quality


agency:

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