Free 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

II. Incident Details

1. Date of Incident: Date of Incident

2. Time of Incident: Time of Incident

3. 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

4. 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

III. Individuals Involved

1. 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

2. Witnesses:

   • Name(s) and Contact Information: List witnesses, including their roles and contact details

   • Witness Statements: Summary of what each witness observed

IV. Incident Description

1. Type of Incident:

   • (e.g., fall, medication error, equipment failure, adverse drug reaction)

2. 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.

3. 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

V. Follow-Up Actions

1. 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.

2. Notifications:

   • Individuals Notified: Include names and titles of individuals or departments notified about the incident (e.g., supervisors, quality assurance, risk management).

3. 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

VI. Additional Information

1. Attachments:

   • Relevant Documents: Include any supporting documentation, such as:

     • Photographs of the scene

     • Incident checklists

     • Clinical notes or assessments

2. 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

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