PARKAR HOSPITAL & RESEARCH INSTITUTE PVT. LTD.

828, Shivaji Nagar, Ratnagiri. PIN: 415639 e-mail: phripl@gmail.com

INCIDENT REPORT FORM

To be filled within 12 hrs of incident & submitted to Nursing Supervisor / TL within 24 hours

Date of Admission Date of Discharge

List of incidents to be
Patient’s Name:
reported (Please tick
the desired option) Inpatient Outpatient
o Patient Fall
Patient’s Admission Diagnosis:
o Medication
Errors
o Bed Sores Admitting Consultant / Consultant In-Charge:
o Needle Stick
Injury
o Surgical site Name of the witness / first person to attend:
Infection
o Mortality
o Adverse Drug Ward / Department Exact location: Date and time of incident
Reactions
o Blood
Transfusion Related Describe what happened and the kind of incident
o Return to OT
within 7 days
o Return to ICU
within 7 days
o Sentinel Events
Impact on the patient: e.g. description of any injury/ harm sustained to patient)
Other Adverse Events
o Patient
Identification Error
o Discrepancy In
sponge / gauge count
o Cautery Burns
o Needle left Name & sign of the consultant:
inside
o others
Sign and name of Employee Code Date and Time
Near Miss reporting staff
o Patient Fall
o Medication
Error Sign & Name of Nursing Employee Code Date and Time
o Patient Supervisor / TL
Identification Error
o Any other kind
of near Miss please
specify
 PARKAR HOSPITAL & RESEARCH INSTITUTE PVT. LTD.
828, Shivaji Nagar, Ratnagiri. PIN: 415639 e-mail: phripl@gmail.com

Infection Control Nurse Infection Control Officer Administrator