Event and Assessment Form

Event and Assessment Form
- The form must be completed by the employee directly related to and on the same day of the event
- Give complete descriptions of what the employee/patient was doing prior to the event taking place.
- Give details of the nature of the injury example bruise, sprain, etc.
- State connecting reason of the incident that were not adhered to and that could have prevented the outcome – e.g. Protocols or Procedures not followed, etc.
- Any additional reports to support the report can be attached.
- If you would like to go back to a previous page, please click on Back at the bottom of each page.
- The HoD must finalise the report once all information has been collected.
Step 1:

Please enter all the relevant details as requested
Branch:*
Please select the branch where the incident took place.
Incident Date:*

DayMonthYear
Date
Hour MinutesAM/PM Option
Reported by:*

First NameLast Name
Date reported:*

DayMonthYear
Date
Email of staff member reporting:
Please add your work email to receive a copy of the submission

Step 2:

Please select the appropriate incident tickbox to compile your form and complete.

The fields will be generated based on the tick boxes selected.
Please select the type of incident*

Data CaptureProcedural/ImagingContrast ExtravasationTraumaMedication/ Contrast VarianceEquipmentSecurityMiscellaneous

Involved parties

Please add names and details of all persons involved with the incident
Step 3:

Add everyone involved
Patient

First NameLast Name QP-number
Patient #2 (optional)

First NameLast Name QP-number
Staff Member

First NameLast Name
Staff Member #2

First NameLast Name
Other parties involved
Please add the person's first and last name with role (eg. Dr Piet Potgieter - Referring doctor)

Step 4:

Please provide a detailed description of events below.
Description of event*
Please only state the facts, no opinions will be taking into account. Please give comprehensive description (How? When?) of events leading up to incident/event.
Action taken after event*
Please only state the facts, no opinions will be taking into account. Please give comprehensive description (Why? How?) of events leading up to incident/event.
File Upload

Any additional reports to support the report can be attached.
Cancelof
Step 5:

Once you have added all the relevant information please click on the Submit button below to submit the event and assessment form to your HOD.

Radiologists Report (if applicable)

To be completed by radiologists involved
After reviewing the information captured for the event, please complete the below Radiologist report with your comprehensive feedback regarding the incident/event related to this case.

You are able to review the detail of this case on the summary email your received or by clicking on the tabs at the top of this form.

Once ready, please click on Submit at the bottom of this page. This will then compile all the information and share it with the relevant HOD to finalize the report.
Radiologist report
Report completed by

First NameLast Name
Date of Report

MonthDayYear
Date
Follow up report (if required/applicable):
Date of submission

MonthDayYear
Date
Follow up report completed

MonthDayYear
Date
Follow up radiologist report (if applicable)
Follow up report completed by

First NameLast Name
Follow up report completed

MonthDayYear
Date

HOD Report

To be completed by Head of Department following a review of event report
After reviewing the information captured for the event, please complete the below Follow up report area with your comprehensive feedback regarding the incident/event related to this case.

Select the appropriate Manager who will review the event and provide the necessary strategic changes where applicable (such as training, policy changes etc.)

Once ready, please click on Submit at the bottom of this page.
HOD Follow up report
Refer for further review

Branch Services ManagerRadiographic Services ManagerHuman Resources

Trauma