CCCRC
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Incident Reporting

Incident Reporting Form

Event Details

To filled by incidence initiator (any staff)
Time of Occurrence
To be confirmed by Quality Team later

Patient Details

If the event related to specific patient (complete the below)
Name
Name
First
Last
Sex

Incidence Details

Maximum file size: 20.97MB

Reported by

(please put your email if you need to receive updates on this incident)
(please put the email of the quality representative or HOD If you need to keep them in the loop)
Do you prefer to be anonymous?

Quality Assessment

Departmental/Sectional Quality Form

Unit Involved:
Please describe why this incident happened and your plan to prevent the recurrence of such incidents in the future.

Maximum file size: 20.97MB

Assessment for the severity of events according to the following scoring levels:

Please indicate the department director or his/ her designee comments/ action

For more investigation 1

Please describe why this incident happened and your plan to prevent the recurrence of such incidents in the future.

Maximum file size: 20.97MB

For more investigation 2

Please describe why this incident happened and your plan to prevent the recurrence of such incidents in the future.

Maximum file size: 20.97MB

For more investigation 3

Please describe why this incident happened and your plan to prevent the recurrence of such incidents in the future.

Maximum file size: 20.97MB

Quality Assurance and accreditation section form

Assessment for the severity of events according to the following scoring levels:

1. Improper patient identification problem
18. Medical supplies
2. Ineffective communication and handover
19. Resuscitation service
3. Critical result reporting
20. Clinical Alarm System Management
4. Verbal and telephone order management and documentation
5. High alert medication (including LASA and high concentrated electrolytes)
7. Safe surgery (consent, site marking, and time out)
11. Patient transportation

Incident Validation

To be filled by Quality Team
Action validation Needed:
Validation status
CCCRC
X