WHEN SHOULD I FILL THIS OUT:

• An incident occurs that adversely affects or threatens to affect the well-being of a patient, personnel, visitor, student, contracted worker and/or property of CAPS.
• Anyone (patient, personnel, visitor, student, contracted worker, etc.) was injured or had/has the potential to be injured.
• There was CAPS property damage or potential property damage.
• Any of the following occur: obscene or harassing call, unruly/abusive patient or visitor, security incident (involving a computer, patient information, theft, property loss or criminal activity), medical equipment failure or user error, known or suspected case of attempted suicide (patient), termination of services (patient), emergency, disaster, civil disturbance, bomb threat, severe weather, or utility failure.
• A minor chemical spill is cleaned up using the spill kit, notify the Safety Officer after you have cleaned up the spill so that the Incident Report can be completed together.
• An exposure incident or sharps injury occurs, complete the Exposure Incident Report in the Exposure Control Plan & Log instead of the general Incident Report.
• An adverse drug event occurs, complete the adverse drug event form instead of the general Incident Report. Contact the head of the STI department to complete this form together.
  
  

The Incident Report should be completed immediately once the incident is over, by the personnel who first witnessed or discovered the incident, or by the personnel most closely involved in the occurrence.

Incident Description Instructions:

• A useful guide may be: Who, What, Where, When, Why.
• Documentation should consist only of facts stated in a clear, concise, objective, comprehensive, and professional manner.
• Only include information that is relevant to the incident.
• Describe relevant events leading to the incident.
• For privacy, use “patient” instead of the patient’s name or initial. When an incident involves incapacitated personnel, use “nurse on duty”, “PCS on the shift”, etc. instead of personnel’s name for privacy.
• Unless necessary to document a medical incident, do not include any medical information, instead reference the case number if needed.
• Describe any actions that were taken immediately following the incident (e.g., first aid administered, emergency services called, safety protocols activated).
• List any damages to property or equipment, and the severity of injuries to individuals, if applicable.
• Check any relevant policies to see if any specific information needs to be included. For example, see the OBSCENE, HARASSING, OR THREATENING CALLS or ULTRASOUND INCIDENT REPORTING or SUICIDE AND SEVERE EMOTIONAL DISTRESS policy, etc., if relevant.
  

Possible Contributing Causes Instructions:

• Documentation should consist only of facts stated in a clear, concise, objective, comprehensive, and professional manner.
• Include any contributing factors such as unsafe conditions, human error, or equipment failure.
• Only include information that is relevant to possible contributing causes.
• For privacy, use “patient” instead of the patient’s name or initial. When an incident involves incapacitated personnel, use “nurse on duty”, “PCS on the shift”, etc. instead of personnel’s name for privacy.
• Unless necessary to document a medical incident, do not include any medical information, instead reference the case number if needed.
• Check any relevant policies to see if any specific information needs to be included. For example, see the OBSCENE, HARASSING, OR THREATENING CALLS or ULTRASOUND INCIDENT REPORTING or SUICIDE AND SEVERE EMOTIONAL DISTRESS policy, etc., if relevant.

Before submitting the report contact Heidi, Maggie, Julie W. or Julie D. and review your entries to help ensure proper information is provided.