Medical Incident Report Outline

I. Report Overview

Date of Incident: Date of Incident
Time of Incident: Time of Incident
Reporting Individual:
- Name: [Your Name]
- Position/Title: Job title
- Department: Department/Unit
Contact Information:
- Phone Number: Direct line
- Email Address: Professional email

Date of Incident: Date of Incident
Time of Incident: Time of Incident
Location of Incident:
- Specific Location: Room number, department, or area
- Facility Name: Hospital/clinic name
- Description of Environment: Brief description of the setting, including any hazards or relevant conditions
Description of Incident:
- Narrative of Events: Provide a detailed chronological account of the incident, specifying:
  - Initial circumstances leading to the incident
  - Actions taken by involved parties before the incident
  - Exact nature of the incident
- Contributing Factors: Identify any factors contributing to the incident, including:
  - Environmental issues (e.g., wet floors, equipment malfunction)
  - Human errors (e.g., communication breakdown, procedural lapses)
  - Equipment-related issues

Staff Involved:
- Name(s) and Role(s): List of all staff involved, including their titles, roles, and any relevant training
- Involvement in the Incident: Brief description of their involvement
Witnesses:
- Name(s) and Contact Information: List witnesses, including their roles and contact details
- Witness Statements: Summary of what each witness observed

Type of Incident:
- (e.g., fall, medication error, equipment failure, adverse drug reaction)
Immediate Actions Taken:
- Medical Interventions: Describe all actions taken immediately following the incident:
  - First aid measures
  - Notifications to emergency services or other departments
- Patient and Family Communication: Document any information provided to the patient and their family regarding the incident.
Assessment of Injuries:
- Type and Severity of Injuries: Detail all injuries sustained:
  - Body part(s) affected
  - Severity classification (e.g., minor, moderate, severe)
  - Initial medical assessment findings
  - Treatment provided

Further Medical Evaluation:
- Recommended Tests or Treatments: Specify any tests ordered and treatments initiated following the incident.
- Referrals: List any referrals made to specialists or additional medical personnel.
Notifications:
- Individuals Notified: Include names and titles of individuals or departments notified about the incident (e.g., supervisors, quality assurance, risk management).
Preventive Measures:
- Recommendations: Outline suggested changes or interventions to prevent similar incidents in the future:
  - Policy changes
  - Training or educational needs identified
  - Equipment maintenance or replacement recommendations

Attachments:
- Relevant Documents: Include any supporting documentation, such as:
  - Photographs of the scene
  - Incident checklists
  - Clinical notes or assessments
Investigation Summary:
- Findings and Conclusions: Provide a summary of any investigations conducted, including:
  - Conclusions drawn from the investigation
  - Analysis of contributing factors
  - Recommendations based on investigation findings