Incidence 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)

Incidence Details

Maximum upload size: 20.97MB

Reported by

Do you prefer to be anonymous?

Departmental/Sectional Quality Form

The Impact of Event

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

Please describe why this incident happened and your plan to prevent the recurrence of such incidents in the future.
Maximum upload size: 20.97MB
Please indicate the department director or his/ her designee comments/ action

For more investigation

Do you need more investigation?

Quality Assurance and accreditation section form

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
21. Anesthesia and Surgical Care
5. High alert medication (including LASA and high concentrated electrolytes)
22. Supply chain
6. Medication Management
23. Inventory
7. Safe surgery (consent, site marking, and time out)
24. Documentation
8. Risk of Health Care–Associated Infections
25. IT System
9. Patient admission, discharge, and transfer
26. Safety
10. Continuity of care and follow up
27. Security
11. Patient transportation
28. Hazardous materials and waste
12. Patient centered care (consent, education)
29. Fire safety
13. Patient screening and assessment
30. Medical equipment
14. Patient Care
31.Utility systems
15. High risk patients
32. Emergency and disaster management
16. Medical equipment
33. Construction and renovation
17. Infection control issues