Hospital Incident Report

[Hospital Name/Logo]

Hospital Incident Report

Patient/Staff Involved

Name: ____________________________________

Patient ID/Staff ID: _______________________

Department/Ward: _________________________

Date of Incident: _________________________

Time of Incident: _________________________

Location: ___________________________________

Description of Incident:
Provide a thorough account of the incident, including the circumstances leading up to it, any medical procedures or interventions involved, and the outcome for the patient or staff member. This section should include all relevant details to ensure a clear understanding of what transpired.

Injuries or Complications:
Document any injuries, complications, or adverse effects that resulted from the incident. This could include patient injuries during treatment, staff injuries, or any other medical complications.

Witnesses:
List the names and contact information of any medical staff, patients, or other individuals who witnessed the incident. Their statements may be crucial for understanding the incident in detail.

Immediate Actions Taken:
Outline the immediate response to the incident, such as medical interventions, reporting to supervisors, or contacting the patient’s family. This section should detail all steps taken to address the situation promptly.

Follow-Up Actions:
Detail any actions to be taken following the incident, such as conducting a root cause analysis, reviewing hospital procedures, or providing additional staff training.

Hospital Incident Summary Table:

Reported By:

Name: ____________________________________

Position: _______________________________

Signature: _______________________________

Date: ___________________________________