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Unusual Occurance/Incident
Complete the form below as soon as possible after the incident occurs, preferably within 48 hours. Submit as directed (to faculty and/or director). Be brief, concise, objective and without use of unapproved abbreviations.
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Name:
*
Your answer
Today's Date:
Your answer
Course/Instructor
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
AM
PM
Where did the incident occur (Agency/Unit), indicate a specific area (eg. Med Room, Patient room)
Your answer
From the definitions below, select the type(s) of event:
Error: “The act of not completing a planned action as intended or achieving an aim by the means of an incorrect plan; it can occur even when the individual has the knowledge to perform a task correctly.” (QSEN, 2012)
Near Miss: “An incident that did not cause harm; events, situations, or incidents that could have caused adverse consequences and harmed a patient but did not.“ (QSEN, 2012)
Witnessing an error: “A situation where a provider, family member, or other person observes an error or breakdown in practice.” (QSEN, 2012)
Preventing an error: “Any intervention that interrupts the occurrence of an error being made; prevention can occur in many forms.” (QSEN, 2012)
Other:
Indicate the type of adverse event
Error in medication administration
Breakdown in communication (oral or written)
Breakdown in attention and surveillance
Failure to prevent
Failure to intervene
Misinterpretations of orders
Failure to advocate or breakdown in professionalism
Other:
Factors/Issues leading up to the event
Busy assignment
Change in patient VS/Status
Interruptions and/or distractions
Lack of knowledge about a med/procedure
Faulty clinical reasoning or judgment
Failure to advocate or breakdown in professionalism
Failure to properly communicate
Other:
Describe the event:
Your answer
Who did it affected or could have affected? (Patient, Staff, Visitor)
Your answer
Was help available? Did you ask for help? Did you look up the policy and/or procedure before and/or after event occurred?
Your answer
Outcome ; what was the result of this occurance
Capacity to cause harm
Event occurred but did not cause harm
Required intervention to decrease adverse effects
Clear selection
Describe what happened as a result. What did you learn?
Your answer
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