TUBIGON COMMUNITY HOSPITAL

Incident Reporting Form

Notes for using this form

 All incidents require a written report to be completed and submitted to the Head of Office within 24 hours.
 Reporter to complete relevant sections of Pages 1 & 2.
 Timelines are to be adhered to for legal reasons.
 Master copy continuity . It will frequently be required that Pages 1 & 2 will be photocopy and be given to the Head of
Office to meet reporting timeframes. Note that the photocopy will become the master copy during the follow up period.
Originals of Page 1 & 2 should be kept in the master file. Copies may be made for individual’s records, but otherwise
ensure the continuity of one master document.

Incident type (please check)

Client Staff Medication Aggression Biohazard Security Willful Accidental Motor
incident or incident (drug errors, (inc. threat, (includes (breach or damage damage Vehicle
injury or adverse verbal or needlestick) potential) (vandalism) Accident
Not inc. injury reactions) physical
medication assault)
incident
Compulsory +1 & 6 Compulsory Compulsory +2 & 6 Compulsory +3, 6 Compulsory +4 & 6 Compulsory + 6 Compulsory +6 & ?5 Compulsory +1 & 6 Compulsory+5 &

+1 & 6 & ?1 6

Incident severity (please check)

Low Moderate Severe Sentinel event
Minor impact that will not in Requires definitive follow Major event with significant Events of a critical nature
itself significantly affect up and impacts on consequences (e.g. resulting in death)
ongoing work. individual or service.
Verbally advise Management Verbally advise
Lodge report within 24 hours Verbally advise a.s.a.p. Management urgently
Management a.s.a.p.

Incident details:
Your Name: Your position: Contact Phone Number:

Place of work: Incident Location:

Hours into shift when Time of Incident: Date of Incident:

Incident occurred:
Have police been notified: YES / NO Police Report Number:

(1) Injury

Part of Body Injured

( L for left / R for right ) Nature of Injury Offender Case of Injury
[ ]Head [ ]Eye [ ]Intestinal [ ]Crush [ ]Patient [ ]Aggression [ ]Repetitive
[ ]Neck [ ]Nose [ ]Nerve [ ]Anxiety [ ]Staff [ ]Lifting [ ]Slip
[ ]Shoulder [ ]Ear [ ]Respiratory [ ]Break [ ]Visitor [ ]Fall [ ]Splash
[ ]Chest [ ]Mouth [ ]Psychological [ ]Cut [ ]Contractor [ ]Electrical [ ]Trip
[ ]Abdomen [ ]Face [ ]Burn [ ]Unknown [ ]Allergy [ ]Illegal Entry
[ ]Back [ ]Leg [ ]Abrasion [ ]Others,______ [ ]Animal [ ]Push/Pull
[ ]Arm [ ]Foot [ ]Bruise ______________ [ ]Insect [ ]Plant
[ ]Hand [ ]Toe [ ]Strain [ ]Disease [ ]Equipment  
[ ]Elbow [ ]Knee NEAR MISS [ ]Infection [ ]Chemical [ ]Alcohol/Drug  
[ ]Finger [ ]Whole No Injury [ ]Electrocution [ ]Vehicle    
  Body No Damage [ ]Bio    
[ ]Others,_______

(2) Medication Incident (Including Intravenous Fluids)

Categories:
[ ] Wrong drug [ ] Wrong dose [ ] Wrong Intravenous fluid hooked [ ] Not signed
[ ] Wrong time given [ ] Wrong route [ ] Intravenous fluid rate not checked [ ] Other:____________
[ ] Wrong patient [ ] Not given [ ] Allergies not checked

Patient’s name: ____________________________________

Drug / dose / route given: _____________________________
(3) Aggressive Incident
 Type: Threatened Verbal abuse Physical assault
Have you discussed this matter with YES NO If not, do you need assistance with this matter? YES NO
someone?
Was Police attendance required YES NO Did Police attend as requested? YES NO

(Provide narrative description at (6))

(4) Needlestick or other biohazard incident

Type: Cause (if needlestick): Follow up management:
Needlestick Blood Lance Immediate washing
Splash to eye Hollow Bore needle ROD consultation
Splash to mouth Suture needle Baseline bloods
Splash to broken skin Blade Treatment
Other ___________________ Other _________________ Other __________________

(5) Vehicle damage ( Ambulance ).

Circle damaged parts (above), and provide narrative description (below). Attach a sketch/photo if helpful to describe an accident .

Make …………………………… Model…………………………… Year of Manufacture…………………..…… Registration

Number………………………
rear front head mud
door / roof back doors front doors bonnet bumper lights guard seats Tire
boot

rear windscreen back front roof rack rear rear engine rim others
window windows windows bumper lights

(6) Description of incident. Compulsory

(Where relevant please provide ideas for preventing recurrence)

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Witness(s) Name(s): Witness(s) to Sign Here:

For statutory purposes please ensure this form is fully completed and signed Compulsory

Have Mgt been verbally notified: YES / NO

Reporter’s signature: Date and time given
_______________________________________________ to the Head of Office: _______________________________

If the Chief of Hospital is not present to enable processing within timelines, forward directly to the Hospital Administrator.