A.PERSON(s) AFFECTED
*
PATIENT
STAFF
VISITOR
CONTRACTOR
MRN
Person Name
*
Facility
HealthPlus IVF - Jeddah
HealthPlus IVF - Riyadh
Exact Location of the incident
*
Reception
Electrical room
Medical Storage room
Finance office
Waiting Area
Cafee Waiting Area
Toilet Female Patient
Toilet Male Patient
Toilet Special Needs
Semen Collection Room 1
Semen Collection Room 2
Janitor Room (Semen Collection Area)
IVF Lab Director Office
IVF Medical Gases Storage
Cryopreservation Room
Embryology Lab
Andrology Lab
Staff Lounge
Male Staff change Room
Female Staff change Room
Pharmacy
Narcotics office
Pharmacy store
OPD Nursing Reception
Triage Room
Treatment Room
Phlebotomy Area
Hormonal lab
Ultrasound Room 1
Ultrasound Room 2
Exam Room 1
Exam Room 2
Exam Room 3
Exam Room 4
Exam Room 5
Exam Room 6
Exam Room 7
Pat Educ 1
Pat Educ 2
Dr. Fawaz office
Dr. Mazen office
Nursing Manager Office
Prayer Area
Toilet Female Patient (OPD)
Staff Toilet (OPD)
OR Nursing Reception
Medication Preparation Area
Server Room
Recovery Area Store
Recovery Bed 1
Recovery Bed 2
Recovery Bed 3
Recovery Bed 4
Recovery Bed 5
Recovery Bed 6
Recovery Bed 7
Recovery Bed 8
Recovery Bed 9
Recovery Bed 10
Recovery Male change room
Recovery Female change room
Patient Toilet Recovery Area
ICU room
Isolation Room
Holding Recovery Room
Doctors Lounge Room
Recovery Staff Toilet
Medical Waste Room
Solid Utility Room
Decontamination Room
Sterilized Room
OR Store
Hand Scrub Area
OT 1 - OR
OT 2 - OR
ET 1
ET 2
Janitor Room OR
Lifts
Stairs
Parking
Other
Example : consultation room, corridor, lobby ....
Please, specify
B. DESCRIPTION
Date and time of the incident
*
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
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53
54
55
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57
58
59
Minutes
AM
PM
AM/PM Option
Description of actual or potential incident
*
Please include the immediate response & outcome (include an extra sheet if needed)
Attach a support document, if any
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C. CONTRIBUTING FACTORS
*
Please include any factors contributing to the incident including : staff factors e.g.fatigue, skill/knowledge deficit, failure to follow policy, communication problem, patient factors
WHAT IMMEDIATE CORRECTIVE ACTION TAKEN?
*
D. HOW COULD INCIDENT HAVE BEEN PREVENTED
*
e.g. Equipment check before use, better written or verbal communication
E. TYPE OF EVENT
*
1. TREATMENT/PROCEDURE
2. CODES/SECURITY
3. PATIENT ACTIVITY
4. COMMUNICATION/DOCUMENTATION
5. LABORATORY SPECIMEN
6. EQUIPMENT/PRODUCT/DEVICE
7. MEDICATION VARIANCE
8. INFECTION CONTROL
9. INFORMATION SECURITY
10. MISCELLANEOUS
1. TREATMENT/PROCEDURE
Deviation from established procedure
Patient Identification
Delay
Operating room cancellation
Blood Adverse Reaction
Other
2. CODES/SECURITY
Theft/missing property
Code Blue
Security Issue
Property Damage
Fire
Other
3. PATIENT ACTIVITY
Assault/Violence/Threat
Dissatisfied Patient/family
Smoking
Fall
Other
4. COMMUNICATION/DOCUMENTATION
Chart Documentation
Consent Form
Code of Conduct
Staff Communication
Other
5. LABORATORY SPECIMEN
Mislabeled Specimen
Sample mix - up
Other
6. EQUIPMENT/PRODUCT/DEVICE
Tempered with
Disconnect/ Dislodge
Malfunction/Defect
Other
7. MEDICATION VARIANCE
Wrong Drug/IV solution
Wrong Dose
Wrong Patient
Wrong Frequency
Other
8. INFECTION CONTROL
Infection Control
Occupational Health Exposure (e.g. needle stick/sharp injury, body fluid exposure etc.)
Other
9. INFORMATION SECURITY
*
Abuse of privileges
Intrusions against networks
Malware infections
Password confidentiality
Sabotage/ Physical damagen
Suspicious system behavior or failure (hardware/software or communications)
Theft/loss of assets
Unauthorized access to information/ systems
Unauthorized changes to information, applications, systems or hardware
Unauthorized release or disclosure of information
10. MISCELLANEOUS
F. MEDICAL TREATMENT
*
Not applicable
Offered
Refused
Given
Referred outside
G. NATURE OF INJURY SUSTAINED
*
Abrasion, Bruise
Fracture
Burn
Death/at facility
Sprain/Strain
None
Other
I. EMPLOYEE PREPARING REPORT
Employee Name ( Optional)
Employee Tel No (Optional)
Role
*
Doctor
Nurse
Allied Health
Admin
Other
Employee email for feedback notification
example@healthplusivf.com
Reporting Department
*
Please Select
Biomed
Facility
HR
IT
IVF Lab
Nursing
Operations / Admin
Pharmacy
Physician
Medical Lab
QC
Finance
Coordinators
Reporting Head - Hidden
*
Please Select
Biomed
Facility
HR
IT
IVF Lab
Nursing
Operations / Admin
Pharmacy
Physician
Medical Lab
QC
Finance
Coordinators
Department HOD
Department HOD Email -- Hidden
Submit your incident report
Quality Followup section (Department feedback)
Department Feedback Date
-
Day
-
Month
Year
Date
What were the contributing factors that led to the adverse event ?
What measures were taken by the department to improve the process or to prevent similar adverse in the future ?
Upload support document,if any
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SAVE & UPDATE
Quality Final Evaluation section
Final Evaluation date
-
Day
-
Month
Year
Date
Log Number
Justified or Unjustified
Justified
Unjustified
If unjustified, please specify reason
QA : What were the contributing factors that led to the adverse event ?
QA :What measures were taken by the department to improve the process or to prevent similar adverse in the future ?
Severity Level
Level1 Near Miss/No Harm/Unsafe Condition
Level 2 Minor
Level 3 Moderate
Level 4 Major
Level 5
Type of incident
Near Miss
Adverse Event
Sentinel Event
Risk Manager Name
First Name
Last Name
QA : Additional comments/recommendation:
Quality Manager Name
Dr Khalid Omar
Incident Closure
Closed
SAVE & UPDATE
Should be Empty: