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
*
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.”
*
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:
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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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