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:
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Fall/Injury
Medication Error
Vaccine Error
Needlestick
Medical Emergency
Test/Procedure/Treatment Error
HR Issue
Lost/Damaged/Stolen Property
Patient Behavior
Faulty Equipment
HIPAA/Privacy
Cash Handling Error
Chart Documentation/Billing Error
Theft/Vandalism of Employee Vehicle
Other
Employee Job Title
*
Cash Handling Error Type:
*
Posted incorrect payment amount
Posted payment using incorrect payment method
Payment posted to incorrect patient account
Duplicate payment posting
Payment not received but posted in error
Drawer overage
Drawer shortage
Cash drawer not close/reconciled
Posted Payment under incorrect department
Time Employee Started Work on the Day of the Incident
*
Hour Minutes
AM
PM
AM/PM Option
What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
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What Happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker fell20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.”
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What was the injury or illness? Tell us the part of the body that was affected and how it was affected.Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
*
What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”;“radial arm saw.” If this question does not apply to the incident, leave it blank.
*
Location of event:
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Greenfield
Joy
Michigan
Moross
Waterman
West Grand
Mobile Team
Other
Department:
*
Admin
Behavioral Health
Dental
Medical
Not Applicable
Was patient transported via EMS to hospital?
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Yes
No
Did you complete an Emergency Medical Worksheet?
*
Yes
No
Please upload Emergency Medical Worksheet
*
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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 type all witness statement(s):
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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