Event Report

Number (to be assigned by Risk Manager):_________ Instructions: Complete all areas that are applicable to the event. Forward to your supervisor immediately. If the event resulted in death or serious injury NOTIFY YOUR SUPERVISOR AND THE CHIEF NURSING OFFICER IMMEDIATELY. DO NOT COPY, PLACE, OR REFER TO THIS REPORT IN THE MEDICAL RECORD.
1) Demographics
Identification:
Day of the Week: MonTuesWedThursFriSatSun
Date of Event:
Time of Event:
Name:
Email:
Address/ Room Number:
Phone Number:
Age:
Sex:
MaleFemale
2) Location of Issue/Occurrence
AdministrationPre-OperativeElevatorsEndoscopyNursing UnitI.C.U.LobbyHallwaysOutpatientParking lotsOperating RoomRadiologyRecoveryStairwellsPATOther
3) Generic Screens *Document medication errors under section 5
4) Was the person injured? NoUnknownDeathYes , if yes complete next section
Minor
AbrasionBruiseSkin TearRashLacerationBroken/Chipped ToothOther
Moderate
Allergic reactionBurnElectric ShockNausea/VomitingInfiltrationNeedle stickPunctureInfectionExposureTransfusion ReactionOther
Serious
BlindnessBrain DamageCardiac ArrestConcussionDecubitus UlcerDehiscenceFracture/DislocationHearing LossHemorrhageLoss of LimbNeuro ImpairmentOcular ImpairmentParalysisRespiratory FailureOther
Was the attending Physician notified?YesNo
Was family notified?YesNo If so, who (list name)?
Was the person examined by a physician?
Name of Physician:
Date:
Time:
Were tests or treatments ordered? NoYes If yes, explain results X-RaysLabsOther
5) Was a Medication involved? NoYes , if yes complete next section and provide narrative in Section 10
Wrong: DoseMedicationTimePatientRouteOmittedNarcoticDiscrepancyReactionOther
Reasons for Medication Variance
Reasons for Medication VarianceAbsence of order/renewalMedication order not transcribed to MAROrder incorrectly transcribed into eMARStop date not recorded on MARMAR copied incorrectlyIllegible physician orderOrder not received in PharmacyMedication not availableMislabeled MedicationWrong dose/form sentMAR not verified prior to administrationPatient ID band not available/readControlled Substance Administration Record incorrectChange in time/schedulePrevious dose not documented as givenPatient not observed taking medicationExpired medicationMedication not scannedOther
6) Did the Person Fall? NoYes if yes, complete next section
What happened? Fall from bed/ StretcherFall while ambulatingSlip and FallFound on FloorFaintFall from ChairUnobservedOther
What kind of activity privileges did the person have?
Full ambulation/ no limitationsAmbulate with assistanceAmbulate with device:
BR privilege with assistanceBR privilege without assistanceUp in ChairBed RestNot SpecifiedOther
Was the person on fall precautions?NoYes
Were the side rails up? NoYes 1234
What was the bed position? HighLow
Factors that may have contributed to fall: FootwearObstaclesLightingFluids on floorUneven floor/carpet or sidewalkOther
7) Was equipment involved?NoYes, if yes complete next section
Was equipment taken out of service? NoYes
Was equipment:BrokenIncorrectMalfunctioningUnavailableOther
Was Patient? Caught betweenStruck by
Manufacturer:
Model#
Serial#
ID#
8) Was there a loss of property? NoYes, if yes complete next section
Type of Property: DenturesGlassesHearing Aid (s)JewelryClothingMoneyOther
9) List of Witnesses
Name
Address
Phone
10) Description of Incident Enter the facts only do not editorialize or express opinions
Signature:
Date/Time:
11) Follow up report (to be completed by Supervisor)
Signature:
Date/Time:
12) Follow up report (to be completed by Department Manager/Director)
Signature:
Date/Time:
CNO Signature:
Date/Time:
13) Risk Management( comments and resolutions)
No action necessaryRefer to originating dept. for further actionRefer to CNO for action/infoRefer to InsuranceRefer to MECRefer to AdministrationPatient’s chart reviewedReviewed/revised P&PNotify Corporate Legal/QualityOther
Level 0 (Near Miss) - A potential error that was prevented prior to reaching the patient.Level 1 – Error occurred /no harm or injuryLevel 2 – Error occurred /required increased monitoring, but no change in vital signs and no harm/injuryLevel 3 – Error occurred/required increased monitoring/a change in vital signs but no ultimate harm, or requiring increased laboratory testingLevel 4 – Error occurred /required treatment with another drug organ increased length of stayLevel 5 – Error occurred that resulted in permanent patient harmLevel 6– Error occurred that resulted in patient death
QM Name:
Date/Time: