Free Clinical Incident Report Template
Clinical Incident Report
I. Incident Details
|
Date |
Time |
Location |
|---|---|---|
|
June 1, 2050 |
2:30 PM |
[YOUR COMPANY NAME], Medical Ward 4B |
II. Description of Incident
On June 1, 2050, at approximately 2:30 PM, Patient George Simon was administered 500mg of Amoxicillin. Shortly after administration, the patient exhibited signs of an allergic reaction, including hives and difficulty breathing. The patient has a documented allergy to Penicillin, which was clearly noted in his medical chart.
III. People Involved
|
Name |
Role |
Contact Information |
|---|---|---|
|
[YOUR NAME] |
Nurse |
[YOUR EMAIL] |
|
Dr. Mark Lee |
Attending Physician |
[YOUR COMPANY EMAIL] |
|
George Simon |
Patient |
george@email.com |
IV. Immediate Actions Taken
Upon noticing the allergic reaction, the following actions were taken:
-
The administration of Amoxicillin was immediately stopped.
-
The patient was given an injection of Epinephrine to counteract the allergic reaction.
-
Dr. Mark Lee was notified and provided immediate medical attention.
-
The patient was monitored closely for any further adverse reactions.
-
The incident was reported to the hospital's quality and risk management team.
V. Root Cause Analysis
A thorough review of the incident revealed the following contributing factors:
-
The medication order was entered incorrectly into the electronic health record (EHR) system.
-
The nurse administering the medication did not cross-check the patient's allergy information in the EHR before administration.
VI. Recommendations
To prevent similar incidents in the future, the following recommendations are made:
-
EHR System Alerts: Implement an automatic alert system in the EHR that flags any medication orders containing allergens listed in the patient's chart.
-
Double-Check Protocols: Enforce a mandatory double-check procedure for all medication administrations, especially for patients with known allergies.
-
Staff Training: Conduct regular training sessions for all healthcare staff on the importance of verifying allergy information before administering any medication.
-
Audit Procedures: Perform regular audits of medication administration records to ensure compliance with safety protocols.
VII. Signatures
[YOUR NAME], Nurse
June 1, 2050
Dr. Mark Lee, Attending Physician
June 1, 2050
Mr. Eric Berry, Quality Officer/Reviewer
June 1, 2050
