🚨 Patient Safety

Incident Reporting Form

Confidential — For patient safety improvement only. All staff are encouraged to report without fear.

This report is confidential and used solely for safety improvement.

* Date of Report

* Date of Incident

* Department / Ward

* Harm / Near Miss Involved

Patient Staff / HCW Attendant Other

* Severity Category

A Circumstances with capacity to cause error (no error yet) B Error occurred but did not reach the patient C Error reached patient, caused no harm D Reached patient, monitoring/intervention required, no harm confirmed E Temporary harm, intervention required F Temporary harm, hospitalization prolonged G Permanent harm to patient H Life-sustaining intervention required (ICU, MV, vasopressors) I Patient death

* Description of the Incident

* Immediate Actions Taken

* Was the supervisor notified?

Yes No

Lessons Learned & Recommendations

✅

Your Ticket Number

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