KBTH PATIENT/STAFF INCIDENT NOTIFICATION FORM

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Consistent with the global and national patient/staff safety agenda, KBTH seeks to improve upon the safety of care that is provided to its patients/staff. In view of that, the hospital seeks to learn from the occurrence of adverse events/incidents and design effective systems to avert any future occurrence. Whatever information you have provided will be solely used for the intended purpose of improving the quality and safety of care. Thank you for your support in improving the quality of care outcomes.

SECTION A: GENERAL BACKGROUND INFORMATION

Category of person involved

Staff

Patient

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Folder Number/Patient Name

Age

Sex

Male

Female

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Department *

Other (State below)

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