Clinical Incident Reporting Tool

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To ensure a culture of safety and quality improvement for all our students, this form is to be used by Nursing Students to capture and document incidents that impacts the safety of those who provide care and those receiving care.

Name of Student: *

Student Number: *

Date of the event: *

YYYY

Time of the event: *

Time

Type of event: *

Error

Harmful Event

No Harm Event

Near Miss

Death

Other:

Required

Recipient of injury/ harm?: *

Patient

Staff

Student

Visitor

Volunteer

Required

Type of Incident: *

Medication error

Needle stick

Inadequate preparation for providing patient care

Blood/pathogen exposure

Fall event

Injury to body

Change in patient condition

Deviation in protocols

Equipment or medical device malfunction

Environmental safety-for self, patient, or others

Assault by patient

Physical/ Verbal Abuse

Other:

Required

Who has been alerted of this injury? *

Clinical Instructor

Faculty Advisor

Patient/ Family

Agency Staff

Other:

Required

Placement agency has been informed? *

Yes

Not Applicable

Placement Agency incident report has been completed? *

Yes

Not Applicable

Follow-up Actions Taken:

Nursing Program: *

Collaborative

Post Diploma

Masters of Nursing

Nurse Practitioner

Current Year of Collaborative Program:

Clear selection

Current Semester:

Clear selection

Submit

Clear form

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