1.Event Time & Location/Details:
(Please refer to appendix A)
Date of the Event: 02/01/2022 Time of Incident: 0900H (AM, PM)
Event Location: Patient’s House
Agency: Manzil Medical Services
Responding Department/ Section: Operations Department
Service Agreement: 12/7
Other Involved Departments:
Patient is under HHCS: : □ Yes □ No
4. Factual Description of the Event:
□ Please tick the box if additional information attached
5. Injury occurred ( Yes /  No), if yes please fill information
Type of Injury: □ Physical □ Psychological
Level of Harm:
□ Insignificant □ Minor □ Moderate
Likelihood Category:
□ Rare □ Unlikely □ Possible □ Likely □ Almost □ Certain
For Medication Error only: □A□B □C □D □E
(Please refer to Appendix B)
8- Classification Of person Affected
AIRWAY MANAGEMENT
 Accidental Aspiration
 Accidental removal of tooth
 Airway management Equipment
Failure
 Obstructed Airway
 Delayed intervention
Adjusting of Ventilator Settings
Ventilator Failure
Other
BLOOD/BLOOD PRODUCT
(General Type)
Significant result delayed
(Specific Type)
Other
CARE/SERVICE
COORDINATION
2. Patient Information (Complete only if Incident): 3. What is being reported?
Patient’s Name: Mohammed Nasser Al-Kaabi HC no: 00283700 Incident (Severity
Diagnosis: ALS, Diabetes Mellitus □ 1. Negligible: Events/error that can cause no negative consequences
Chief complaint: _____________ □ 2 Minor harm/damage: Events/error results in minor harm/damage where first aid
Date of Birth: 01/01/1956 treatment only is needed, and no further intervention is required
Gender: □ M / □ F □ 3. Moderate harm/damage: Events/error results in moderate harm/damage that
necessitates hospitalization and required treatment.
□ 4 Serious harm/damage: Events/error results in serious harm/damage, requiring
hospitalizations for intensive treatment and invasive procedure that hinders return to
work
□ 5 Sentinel /Catastrophic that results in unexpected death and or major permanent
loss of functions.
□ Near Miss: Any process variation that did not affect an outcome but for which a
Recurrence carries a significant chance of a serious adverse outcome.
6. To be Completed by Person in Charge at Time of 7.Contributing Factors refer to Appendix C
Incident:
Fall with injury only:  Other Departments/External Bodies □ Patient Factors
Informed? □ Yes □ No □ NA □ Task and Technology Factors
Please specify degree of injury:  Patient family Informed? □ Yes □ No □
□ Major □ Catastrophic □ Individual (staff) Factors
NA
Slight injury: □ No Treatment Required  Patient Informed? □ Yes □ No □ NA □ Team Factors
Slight Injury: □ Frist Aid Required  Has risk assessment been □ Work Environment Factors
Slight Injury: □ Pain- No Treatment undertaken/reviewed following this incident
Required □ Organizational & Management Factors
(Risk Assessment Tool): □ Yes □ No □ NA
Moderate Injury: □ Treatment Required □ Institutional Context Factors
□F □G□H □I Sever Injury: □ Treatment /Surgery
Required □ Equipment Involve/malfunction □YES □ NO If Yes (Specify)
Death □
 Outpatient Patient (At Home)  Employee  Quarantine facility  Other
GENERAL INCIDENT TYPE
CARE/SERVICE CARE/SERVICE CARE/SERVICE EMPLOYEE EMPLOYEE GENERAL EMPLOYEE GENERAL FALL
COORDINATION COORDINATION COORDINATION GENERAL INCIDENT INCIDENT INCIDENT
Specific Incident Type
 delay/lack of response to patient  patient/family refusal to be seen  patient/family refusal to go to ED inappropriate behavior  abuse/assault (physical)-  COVID-19 positive -  in shower/tub
condition by male staff towards staff aggressor community acquired
 handover issue  medical equipment  patient/family refusal to go to ED illness at work  abuse/assault (physical)-  COVID-19 positive -  slipped/twist
by EMS victim occupational acquired
 failure to obtain appropriate  patient/family refusal to be  referral/transfer issues late to report to work  abuse/assault (verbal)-  COVID-19 high risk exposure -  From bed-no rails
assistance examined by physician aggressor community
 failure to follow patient care Lack of caregiver  refusal to attend family  needlestick injury  abuse/assault (verbal)-victim  COVID-19 high risk exposure -  from wheelchair
orders conference occupational
 insufficient handover – nurses Patient refusing transfer to  Refusal to discontinuation  sexual  argument with colleague  COVID-19 positive - unknown  from chair
another Agency Other assault/harassment by origin
patient/visitor
referral/transfer issues patient/family refusal of EMPLOYEE GENERAL  sharp/surgical blade  argument with patient/family  COVID-19 suspected -  from crib
admission to hospital injury unknown origin
INCIDENT (General Type)
staff failure to report for duty patient/family refusal of  chemical splash injury staff involved in a road  blood/body fluid splash  COVID-19 suspected low risk  from bed-over
discharge from HHCS (Specific Type) traffic accident injury exposure - occupational foot/headboard
staff non-adherence towards patient/family refusal of HHCS  cut wound  theft/suspected theft  breach of privacy COVID-19 suspected high risk  while running/playing
frequency of visit staff  Suicide Attempt exposure – community
Other
 unavailable interpreter/language  Other disorderly person  threat by patient auto accident FALL  from toilet/commode
bank issues Other
(General Type)
 (General Type)
Admission issues (Specific Type)  unplanned admission to exposure to blood/body fluid  threats - verbal or MEDICATION INCIDENT  from/on stairs (Specific  from bed-over rails
ward/unit physical Type)
(General Type)
 Communication  communication issue exposure to other hazardous  verbal/physical assault administering  while being held by caregiver  while ambulating
issue/miscommunication (Care material by patient/visitor medication/fluid (Specific Type)
Partner)
 Failure to collect supplies from  patient/family refusal to be fall  breach of dispensing medication/fluid  transfer/lift Other
store examined by HHCS confidentiality

 medical consumable supplies patient/family refusal to answer fracture  incorrectly performed monitoring medication/fluid  unknown - found on
telephone test floor/unwitnessed

 Medical Records File-not  Refusal to keep back up machine prescribing medication/fluid  While standing
available

Patient/family refusal of patient/family refusal of home transcribing medication/fluid

discharge from hospital visit

Other

GENERAL INCIDENT TYPE

MEDICATION/FLUID SKIN/TISSUE SKIN/TISSUE VASCULAR LAB ENVIRONMENT SAFETY/SECURITY/ INFECTION CONTROL
HANDLING & SUPPLY ISSUE SPECIMEN/TEST CONDUCT

Specific Incident Type

 expired/outdated medication  Phlebitis grade 0  pressure ulcer stage 3 - hospital  bleeding puncture site  incorrect specimen  Unsafe home environment  Inappropriate behavior  needlestick injury
(Specific Type) acquired towards staff

 incorrect storage  Phlebitis grade 1 Other  extravasation   Walking surface-wet  Self-injury  PEG site infection
incorrect label/labelling
error

 medication supply - no stock  Phlebitis grade 2  Infection puncture sure  wrong container/tube  Wall/floor issue  Sexual assault/harassment  sharp/surgical blade
available
Line/Tube injury

 unordered medication  Phlebitis grade 3  Necrosis gangrene  lost specimen  Water leak  Threats-verbal or physical  tracheostomy site
 accidental dislodgement infection

 wrong dose/strength  Phlebitis grade 4  Phlebitis (PICC/PIV only)  wrong test performed  Snake-live/crawling  Unauthorized smoking  failure to isolate
Other  circulation impeded

SKIN/TISSUE  dehiscence/evisceration  PICC line insertion complications  improper specimen  improper storage-chemical  abuse/assault (physical)-  lack of notification to
storage aggressor family about CD
 defective intravenous cannula

 burn - 1st degree  diaper dermatitis  PICC catheter defective  hemolyzed sample  poor lighting  abuse/assault (physical)-  exposure to blood/body
(Specific Type)  defective catheters/line tubing victim fluid

 burn - 2nd degree  pressure ulcer stage 1 -  Open lesion  Other  presence of rats/rodents  abuse/assault (verbal)-  break in isolation
community acquired  difficult insertion aggressor

 burn - 3rd degree  pressure ulcer stage 1 - HHCS  necrosis DIAGNOSIS AND  sharps not secured  abuse/assault (verbal)-victim  dirty/untidy medical
acquired  disconnected device
TREATMENT
 burn - 4th degree  pressure ulcer stage 1 - hospital  cellulites patient/family non-  Spill-other  domestic quarrel  personal protective
acquired  discontinued inappropriately compliance to instructions equipment issue

 pressure ulcer deep tissue injury  pressure ulcer deep tissue injury Other  patient/family  Telephone  Suicide attempt  sharps issue - wrong
- hospital acquired - community acquired  discontinued without order refusal/noncompliance to malfunction/down disposal
procedure
 pressure ulcer deep tissue injury  Phlebitis grade 5  patient/family Animal Bites Other Other
- HHCS acquired  I.V line tubing - kink/twist/curve refusal/noncompliance to
medication
  ecchymosis pressure ulcer stage 2 community  Readmission within 24 Other
acquired  line not changed hours

 eczema  pressure ulcer stage 2 - HHCS  adverse drug reaction

acquired  patient discharged with IV line

 hematoma  pressure ulcer stage 2 - hospital discharge within 24

acquired  removal-accidental hours of admission (DAMA)

 impetigo  pressure ulcer stage 3 - patient refusal/non-

community acquired compliant with treatment
 tubing leak

 Infected wound  pressure ulcer stage 3 - HHCS  wrong size inserted  delayed treatment
 Abscess acquired  Delayed/wrong/no
order for treatment
 Failure to assess patient

 blister  bruise  patient and family

Refusal /Non-Compliance to
 wrong insertion location wound care

 abrasion  Boils Other

 wrong patient

9. OVA Completion 10. Incident Risk Classification &Rating (Please refer to D, E & F)

 Event Reported within 24 Yes  No

Hours
 Initial Action done and  Yes  No
forward to PNS department
 OVA Closed  Yes  No

Specific incident
Please shade the circle with appropriate rating in the above table

11. immediate action taken by the nurse who identified and report the incident.
Rapid antigen test swab done within the day and tested positive, RT-PCR swab test done thereafter in a private clinic and do 10 days self isolation for asymptomatic

12. Action taken by the Agency management team.

 Reviewed by:

Reported by: Name: _____________________________ Professional Title: _________________

Name: Judy Von Junco Professional Title: Registered Nurse License No: __________ Contact No Signature: ____________________ Date: / /

License No: N29489 Contact No 55259091 Signature: ____________________ Date: 01/07/2022