Incident & Near-Miss Report
Submitted By:
*
First Name
Last Name
E-mail Address:
example@example.com
Is this an incident or a near-miss?
*
Incident
Near miss
Date of event (if multiple dates, enter start date)
*
-
Month
-
Day
Year
Date
Time of event
*
Hour Minutes
AM
PM
AM/PM Option
Name(s) and/or MRN(s) (if patient) of people involved:
*
Incident/Near-miss type:
*
Fall/Injury
Medication Error
Vaccine Error
Needlestick
Test/Procedure/Treatment Error
HR Issue
Lost/Damaged/Stolen Property
Patient Behavior
Faulty Equipment
HIPAA/Privacy
Cash Handling/Billing Error
Other
Location of event:
*
Greenfield
Joy
Michigan
Moross
Waterman
West Grand
Mobile Team
Other
Department:
*
Admin
Behavioral Health
Dental
Medical
Not Applicable
Were any witnesses present? If so, please get a witness statement if possible.
*
Yes
No
Name of witness(es):
Is patient discharge being requested?
*
Yes
No
Describe the event in detail:
*
Describe actions taken or actions needed to address the event:
*
Please upload witness statements here:
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**If management needs to add comments to Incident report please email: Risk@covenantcommunitycare.org
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