Chapter 4 Safety and Infection Control 99 Copyright Goodheart-Willcox Co., Inc. I. OCCURRENCE: STATUS DATE TIME LOCATION NAME ❑ INPT ❑ OUTPT ❑ VISITOR ❑ OTHER AGE SEX ❑ M ❑ F Diagnosis or Procedure Witness Yes ❑ No ❑ Name ___________________________________________ Dept._______________________________________________ Condition Prior to Occurrence Meds in last 12 hrs (falls only) ❑ Alert ❑ Asleep ❑ Disoriented ❑ Anesthetized II. MEDICATION (All that apply) INTRAVENOUS (Note all that apply) FALL (Complete both sides) ❑ Wrong medication ❑ Wrong amount ❑ Wrong date/time ❑ Wrong pt ❑ Wrong route ❑ Transcription error ❑ Allergic reaction ❑ Omission ❑ Incorrect narcotic count ❑ Other ______________________________ ❑ Name of Med ❑ Wrong solution ❑ Wrong medication ❑ Wrong rate ❑ Wrong time ❑ Infiltration ❑ Transcription error ❑ PCA error ❑ Blood transfusion ❑ Hyperalimentation ❑ Other ______________________________ ❑ Ambulating ❑ In BR ❑ Out of bed ❑ To FRM B/R ❑ Other ❑ PT has fallen prev ❑ Restrained ❑ Side rails up ❑ Side rails down Surgical — Please Comment ❑ Delay ❑ Consent mismatch ❑ Unplanned return ❑ Incorrect count ❑ Unplanned repair/removal ❑ Arrest ❑ Death ❑ Anestheia related ❑ Other _______________________________ Equipment Consent ❑ Not available ❑ Disconnected ❑ Procedure not followed ❑ Nonsterile ❑ Malfunction ❑ Other _____________________________ ❑ Descript. of item _____________________ ❑ Name written ❑ Mismatch ❑ Refused to sign ❑ Incomplete ❑ Other ____________________________ AMA Pressure Sore (Complete both sides) Other ❑ AMA signed ❑ Not signed ❑ AWOL ❑ Other ____________________________ ❑ On admission ❑ Hospital acquired ❑ Picture taken ❑ Stage I ❑ Stage II ❑ Stage III ❑ Stage IV ❑ Security ❑ Engineering ❑ Combative pt ❑ Suicide attempt ❑ Fire ❑ Respiratory ❑ Pharmacy ❑ Code blue expired ❑ Code blue survived ❑ Complaint ❑ Self abuse ❑ Lost/damaged article ❑ Hazardous exposure ❑ Burn ❑ Lab ❑ X-ray ❑ Food services ❑ Housekeeping ❑ Other (comment) _________________ III. Severity of Outcome ❑ No Injury ❑ Inconsequential ❑ Consequential IV. Comments & Action V. Follow-up (Director to complete) Name of MD notified Date Time Seen by MD? ❑ Communicated with ____________________________________ ❑ Employee counseled ❑ In-service ❑ Policy change/new ❑ Trend ❑ Other _______________________________ Yes ❑ No ❑ X-ray / Lab / Tests ordered Equipment Yes ❑ No ❑ State _____________ ❑ Sent for repair ❑ Removed from service Reported by — Date — Dept. Persons Involved Dept. Department Director Sign — Date Goodheart-Willcox Publisher Figure 4.4 Most healthcare facilities will have an incident report similar to the one above. What are the major categories of incidents included in this report?