INCIDENT REPORT

IR No......................

I. Please complete this form to record all incidents/accidents (including near misses) of patients, visitors, attendants and staff.
II. Please complete a separate form for each person directly affected.
III. Record fact only, not opinion.
IV. Please report within 24 hours
V. Completing this form does not constitute an admission of liability of any kind by any person.
VI. After completion please forward it to your supervisor who will again send it to Quality Department
VII. Please provide as much precise detail as possible and do not leave blank spaces, indicate none, not applicable, or
unknown where applicable.
VIII. For definitions please refer to glossary.

IF EVENT INVOLVES: □ Patient □ Visitor □ Staff □ Others (please specify)...................................................................................................

Name: .......................................................................................................................................................................................................................

UHID: .......................................................................................... Age: ............................................................................. Sex: □M□F

For Staff, Name........................................................................................ EID: ................................ Department:
..................................................

Date of Incident: (DD/MM/YYYY)....................................................... Time of Incident:................................ (AM/PM)

Incident Place: (Unit/Dept. Name)..........................................................................................................................................................................

Details of the incident:

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Name & Contact of Eyewitness:

Eyewitness Comments:

Indicate Medical Treatment Required: (In case of Injury)

Injury description: Body part(s) involved:…………………………………………………………………………….........…… Type of Injury/illness

(e.g. cut, strain, crush etc): ………………………………………………………………………..…….........

I. First aid given? □ Yes/ □ No; By Whom: …………… ………………………………………….……

II. Treatment by doctor □ Yes/ □ No; Who:…………………… …………….……………….................…….
III. Treated in ER? □ Yes/ □ No; Where:…………………………………………………………………
Name: EID:
(person reporting the incident)

Department: Date: Time:

(person reporting the incident)
Incident Report submitted to:

Seal & signature of person filling report: Name: ……………………………….......................…………………...............….

Designation: ……………………………………...............……...........…………..

Department: ……………… …………………………...……….....................……

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Comments of HOD:

For Quality Department Use Only:

Grading of Incidence and decision for Root Cause Analysis: (if Score is 8 or greater than 8): Use the table for
scoring

FREQUENT (4) OCCASIONAL (3) UNCOMMON (2) REMOTE (1)

CATASTROPHIC (4) MAJOR (3) MODERATE (2) MINOR (1)

Score Grade of Incidence Definition Concurrence: Yes/No/Pending for

Root Cause Analysis
Need immediate intervention
Extreme (>12 – 16) and start doing an RCA

High (8 – 12) Need immediate intervention

and start doing an RCA
Medium (>4 ‐ <8) Intervention is required

Low (1 ‐ 4) No immediate intervention is

required
Type of Incident: □ Clinical, □ Non‐clinical
□ Near Miss □ Sentinel Event □ Others
Cause analysis:

Comments of Quality Officer:

Follow Up with: Follow Up date:

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GLOSSARY

□ IRN : Stands for Incident Report Number

□ Support Staff : It includes the members of departments like security, housekeeping, food and beverage.
□ UHID : Unique Hospital Identification Digit
□ A and E : Accident and Emergency
□ OP : Outpatient
□ DC : Daycare
□ IP : Inpatient
□ Variance : It is defined as any event or circumstances not consistent with the standard routine operations of the hospital
and its staff or the routine care of a patient / visitor.
□ ERROR : an unintended act, either of omission or commission, or an act that does not achieve its intended outcome.
□ NEAR MISS : any process variation which did not affect the outcome but for which a recurrence carries a significant chance of
a serious adverse outcome.
Near misses include events ranging from “near fall event” to administration errors which if it had occurred would
have caused serious adverse outcomes.
An action which could have caused (but did not cause):
• Unanticipated death unrelated to the natural course of the patient’s illness or underlying condition
• Major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition;
• Wrong‐site, wrong‐procedure, wrong‐patient surgery; and
• Infant abduction or infant who was sent home with the wrong parents
□ SENTINEL EVENT: A sentinel event is an unanticipated occurrence involving death or serious physical or
psychological injury. Serious physical injury specifically includes loss of limb or function. Such events are called sentinel
because they signal the need for immediate investigation and response. Labaid Cancer Hospital and Super Speciality
Centre, Dhaka establishes an operational definition of a sentinel event that includes at least an unanticipated death,
including, but not limited to -
▪ death that is unrelated to the natural course of the patient’s illness or underlying condition (for example, death from a
postoperative infection or a hospital‐acquired pulmonary embolism)
▪ death of a full‐term infant; and
▪ suicide;
▪ major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition;
▪ wrong‐site, wrong‐procedure, wrong‐patient surgery;
▪ transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or transplanting
contaminated organs or tissues;
▪ infant abduction or an infant sent home with the wrong parents; and
▪ rape,
▪ workplace violence such as assault (leading to death or permanent loss of function); or
▪ homicide (willful killing) of a patient, staff member, practitioner, medical student, trainee, visitor, or vendor while on
hospital property.

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