Incident form

Patient safety incident report form - ambulatory care (international)

A report form for patient safety incidents or near misses in ambulatory care, covering what happened, people involved, harm, immediate actions, and follow-up.

Fill it in online - free, no account needed. 26 questions.

What it is for

This template provides a structured way to report patient safety incidents and near misses in ambulatory care.

The full question list

1. Incident Details

  1. Date and time the incident occurred *
  2. Date and time the incident was identified *
  3. Type of incident *
  4. Location of incident (e.g., waiting room, consultation room 3) *
  5. Brief description of what happened *

2. People Involved

  1. Role of person completing this form *
  2. Patient identifier (e.g., medical record number, initials) *
  3. Was a staff member involved in the incident? *
  4. Role(s) of staff member(s) involved (if applicable)

3. Harm and Immediate Actions

  1. Level of harm to patient *
  2. Description of harm caused to the patient (if any)
  3. Immediate actions taken to mitigate harm or prevent recurrence *
  4. Was the patient informed of the incident? *
  5. Was the patient's representative informed of the incident? *
  6. Date and time patient/representative was informed (if applicable)

4. Reporting and Review

  1. Was the immediate manager informed of the incident? *
  2. Date and time manager was informed
  3. Does this incident require a deeper review (e.g., root cause analysis)? *
  4. Date deeper review initiated (if applicable)
  5. Summary of review findings (if applicable)
  6. Corrective actions identified from review (if applicable)
  7. Date corrective actions implemented (if applicable)
  8. Date incident formally closed (if applicable)

5. Sign-off

  1. Name of person completing this form *
  2. Date and time of completion *
  3. Signature of person completing this form *

References

How the score works

The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.

Questions

What is an 'ambulatory care' setting?

Ambulatory care refers to medical services performed on an outpatient basis, meaning the patient does not stay overnight in a hospital. This includes clinics, doctor's offices, and outpatient surgery centers.

When should this form be completed?

This form should be completed as soon as possible after a patient safety incident or near miss is identified, to ensure accurate and timely reporting of all relevant details.