Free Patient Safety Incident Report Template
Patient Safety Incident Report
I. Incident Details
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Date of Incident: May 15, 2050
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Time of Incident: 2:30 PM
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Location: Ward 3B, [YOUR COMPANY NAME]
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Patient Name: [PATIENT'S NAME]
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Patient ID: JD-816419
Description of Incident:
While transferring the patient from the bed to a wheelchair for transport to the radiology department, the patient slipped and fell due to a wet spot on the floor near the nurse's station. The nursing staff attempted to catch the patient but were unable to prevent the fall. The patient landed on their right side and complained of immediate pain in the right hip area.
II. Clinical Assessment
Injuries: The patient sustained a bruise on the right hip and complained of tenderness in the area.
Vital Signs at the Time of Incident:
|
Parameter |
Reading |
|---|---|
|
Blood Pressure |
120/80 mmHg |
|
Pulse Rate |
82 bpm |
|
Respiratory Rate |
16 bpm |
|
Temperature |
98.6°F |
III. Immediate Actions Taken
The nursing staff immediately assessed the patient's condition, administered 2 mg of morphine sulfate intravenously for pain relief, and immobilized the right hip area with a pillow while awaiting further evaluation. The incident was reported to the charge nurse, who alerted the attending physician and initiated an X-ray request for the patient's hip.
IV. Follow-Up Actions
The patient was transported to the radiology department for a hip X-ray, which revealed no fractures. However, due to the patient's persistent pain and discomfort, the attending physician ordered a consultation with the orthopedic department. The patient was kept under observation for several hours and was subsequently discharged with instructions for pain management (acetaminophen 500 mg every 6 hours) and follow-up with their primary care physician within 48 hours.
V. Witnesses
Witnesses Present:
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Stephen Conroy (Registered Nurse)
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Crystal Mock (Licensed Practical Nurse)
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Jacqueline Givens (Patient Care Assistant)
VI. Supervisor/Manager Informed
Supervisor/Manager Notified: Yes
Name of Supervisor/Manager: Dr. Esther Lilley
Date/Time Notified: May 15, 2050 - 2:45 PM
VII. Additional Comments
The incident occurred due to a spillage from a nearby water cooler, which was promptly cleaned up following the incident. Staff have been reminded to remain vigilant regarding environmental hazards and to ensure patient safety during transfers. An incident debriefing session will be scheduled to review the circumstances leading to the incident and identify opportunities for improvement in patient handling procedures.
VIII. Report Prepared By
Prepared By: [YOUR NAME]
Position: Head Nurse
Date: May 15, 2050
[YOUR COMPANY NAME]
[YOUR COMPANY ADDRESS]
Phone: [YOUR COMPANY NUMBER]
Email: [YOUR COMPANY EMAIL]
Website: [YOUR COMPANY WEBSITE]
