Incident Report (Non-Employee)
Incident Location
*
Inpatient
Day Hospital
Outpatient
Which Outpatient Location?
Marlton
Northfield
Pennsauken
Vineland
Washington Township
Date/Time of Incident:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Division / Discipline Involved:
*
Please Select
Nursing
OT
PT
ST
TR
Nutrition
Respiratory
Pharmacy
Office/Administration
Other
Division/Discipline Involved, Other:
*
Person Affected:
*
Please Select
Patient
Caregiver
Employee
Visitor
Other
Person Affected, Other:
*
Name of Person Affected:
*
First Name
Last Name
Witness?
*
Yes
No
Witness Name:
*
First Name
Last Name
Nurse Notified?
*
Yes
No
Name of Nurse:
*
First Name
Last Name
Date/Time Nurse Notified:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Physician Notified?
*
Yes
No
Name of Physician:
*
First Name
Last Name
Date/Time Physician Notified:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Occurrence
Site Area:
*
Patient Room
Lobby
Therapy Room
Hallway
Floor
Dining Room
Bathroom
Nurse's Station
Playroom/Teen Room
Outpatient
Gym
Other
Occurrence of Injury
Injury / Possible Injury?
*
Yes
No
Injury Type
Location of Injury:
Specific Injury Type:
*
None
Abrasion
Allergic Reaction
Burn/Skin Irritation
Cellulitis
Fracture
Decannulation
Hemorrhage
Infiltration
Soft Tissue
Perforation
Respiratory/Cardiac Arrest
Change in Cognitive State
Neuro Impairment
Swelling
Unknown
Other
Medication/Nutrition/Food Service
Medication/Nutrition/Food Service Related?
*
Yes
No
Type of Medication Incident: (Select All That Apply)
*
Administration without order
Duplication
Omission
Prescription Error
Transcription Error
TPN
Reaction
Incorrect Formula
Incorrect Patient
Incorrect Medication
Incorrect Dose
Incorrect Route
Incorrect Time
Other
IV Related?
*
Yes
No
Type of IV-Related Incident: (Select All That Apply)
*
Drug Extravasations
Incorrect Date
Incorrect Solution
Infiltration
Other
Pump Related?
*
Yes
No
Type of Pump-Related Incident? (Select All That Apply)
*
Equipment/Pump Malfunction
Equipment/Pump Operating Error
Cassette/Tubing
Other
Food Service Related?
*
Yes
No
Attach Scan of Tray Ticket
Browse Files
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Choose a file
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of
Type of Food Service-Related Incident: (Select All That Apply)
*
Incorrect Diet Level
Allergen not excluded
Tray sent to wrong patient
Carb-Controlled related
Reaction
Other
Falls/Movement
Falls/Movement Related Occurrence?
*
Yes
No
Symptoms Before: (Select All That Apply)
*
Dizziness
Weakness
S.O.B.
None
Other
Activity:
*
Ambulating with Assistance
Ambulating without Assistance
During Transfer
From Bed/Crib
From Chair/Wheelchair
From Commode/Toilet
While Being Carried
Fall During Therapy/Activity
Other
Condition After Fall: (Select All That Apply)
*
Pain
LOC
Bleeding
Slurred Speech
Edema
Bruising
No Observable Change
Other
Other Fall-Related Issues: (Select All That Apply)
*
Floor Wet/Slippery
Struck by Equipment/Door
Door Closed on Finger, Hand, Foot
Bumped into Door/Wall/Equipment
None of These
Crib Related?
*
Yes
No
Crib Related (Select All That Apply)
*
Side Rail Down
Side Rail Up
Unsafe Sleep Environment
Crib Related: Bubble Top?
*
Yes
No
Supervision:
*
Unattended
Attended
Name of Attendant:
*
First Name
Last Name
Related Information
Last Meal Time:
Last Medication Time:
Napping Prior?
Yes
No
Fall Immediately After Treatment?
Yes
No
Equipment
Equipment Related?
*
Yes
No
Type of Equipment:
*
Crib/Bed
Commode
Shower
Monitors
High Chair
Shower/Tub Bench or Chair
Oxygen
Drains/Tubing
Wheelchair
Stroller
Walker
Stander
Mat Table
Swing
Orthotic
Furniture
Door
Electrical
Toy
CR Monitor not connected to external alarm
Pule Ox Monitor not connected to external alarm
Other
Current Location of Equipment:
*
Manufacturer's Name:
Serial Number:
Procedure
Procedure Related?
*
Yes
No
Type of Procedure-Related Incident:
*
Delayed Response Time
Incorrect Test/Procedure
Lack of Consent
Sedation Related
Injury/Reaction
Not performed as ordered
Delayed
Postponed
Rescheduled
Needle Stick/Sharp Injury (See Infection Control Policy for Follow-Up)
Other
Workplace Violence
Workplace Violence Related?
*
Yes
No
Type of workplace violence incident
*
Verbal Aggression
Nonverbal Aggression
Physical Aggression
Threatening, intimidating, harassing, or humiliating words or actions
Bullying
Sabotage
Sexual Harassment
Physical Assaults
Other
Workplace Violence Detailed Description
*
Miscellaneous
Miscellaneous Incident:
Incident did not meet criteria for any of the categories above
Miscellaneous Incident Type:
*
Dissatisfaction with Care
Security Breach
Personal Property Damage/Loss
Policy/Procedure Not Followed
Patient Behavior
Code Bell Pulled
Lab-Related
Other
Lab-Related Description:
*
Immediate Action Taken
Immediate Action: (Mark All That Apply)
*
Patient Assessed
Treatment Provided
Emergency Order Obtained
Emergency Transport
Non-Emergency Transport
Security Called
911 Called (For Safety/Security Issue)
Administrator On Call Notified
Charge Nurse Notified
Legal Guardian Notifed
DCPP Notified
Other
Administrator On Call Name:
*
First Name
Last Name
Administrator On Call Notified Date and Time:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Charge Nurse Notified Name:
*
First Name
Last Name
Charge Nurse Notified Date and Time:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Legal Guardian Notified Name:
*
First Name
Last Name
Legal Guardian Notified Date and Time:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Comments
*
Attach Separate Document(s) if Needed:
Browse Files
Drag and drop files here
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of
Person Completing Report:
*
First Name
Last Name
Supervisor Responsible for Follow up:
Please Select
Corinne (Outpatient)
Arlyn (Inptient Nurisng)
Dawn (Inpatient Rehab)
Jodi (Dietary Inpatient)
Supervisor Email
*
example@example.com
Check This box if you are The supervisor and need to complete the follow up report
Follow Up
Follow Up Report
Patient Outcome:
*
No medical treatment required
Medical treatment administered
Hospitalization required
Fatality
Other
Cause(s) for Incident (Mark All That Apply)
Policy / Procedure / Education
*
Policy / procedure does not provide needed direction
Policy / procedure / protocol not followed
Person demonstrated understanding of policy but disregarded
Staff member not educated / trained
None of these
Process
*
Physician order not executed
Proper consent form not obtained
Documentation requirements not completed / illegible
Discharge planning not provided
Appropriate orders not obtained
Initial history / assessment not completed
Medical orders, test results, etc. not communicated
Patient / caregiver education not provided / documented
None of these
Equipment / Environment
*
Defective / malfunctioning equipment not reported / removed / repaired
Environmental hazard / standards not maintained
None of these
Medication
*
Error in transcription
Error in Dispensing
Error in Administration
None of these
Safety
*
Patient left unattended
Error in patient identification
Care rendered / response not acceptable to patient
Staff assignments not made according to standard
Staffing below target HPPD
Unsafe physical condition not corrected
Proper body mechanics not used
Fall prevention guidelines not followed
Appropriate de-escalation techniques not used
None of these
Other
Security
*
Entry to unauthorized area
Failure to safeguard personal belongings
None of these
Miscellaneous
*
Unanticipated change in patient's condition
Medical condition unknown at time of occurrence
None of these
Other
Follow-up Done
Policies and Procedures
*
Revise P/P
Develop new P/P
Enforce P/P
None of these
P/P Follow up: Date and Initials
*
Counseling / Education
*
In-service education
Return Demonstration
Preceptor Assignment
Restriction of duties / privileges
Disciplinary action
None of these
Counseling / Education Follow up: Date and Initials
*
Equipment / Supplies / Facility / Condition
*
Immediately tagged / secured
Repair / correct
Recommend change
None of these
Other
Equipment / Supplies / Facility / Condition Follow up: Date and Initials
*
Follow-Up Completed By
*
First Name
Last Name
Follow-Up Completed By Title and Department
*
Follow-Up Completed By Date
*
-
Month
-
Day
Year
Date
Close form and send to Safety Officer and:
*
Nurse Executive / Director of Nursing
Director of OP Services
COMPLETION REPORT EMAIL
example@example.com
Submit
Should be Empty: