Safety Program

Quality and Accreditation Directorate

Incident Reporting Statistics

The Healthcare Organization is responsible for the submission of a quarterly (each 3 months) statistics report for all incidents reported by care providers.
This form is to be prepared by Healthcare Organization Safety and Risk Management committee.

Healthcare Organization:

Report Date: DD / MMM / YYYY

Submitted By: Job Title:

Total number of incidents in Period from ----/------/---- to ----/-------/----

i. No. of incidents occurring in each Department in Period from ----/------/---- to ----/-------/----

Department Jan Feb March April May June July August Sept Oct Nov Dec

Internal Medicine

Pharmacy

……

……

Unclassified

Total

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 ii. Total number of each incident type occurring in Period from ----/------/---- to ----/-------/----:

Sentinel Event Adverse Event No-Harm Near Miss Unsafe Condition

iii. Total number of each (Actual) SAC category incidents occurring in Period from ----/------/---- to ----/-------/----:

SAC I SAC II SAC III SAC IV Unknown

iv. Total number of incidents by Nature occurring in Period from ----/------/---- to ----/-------/---- :

Patient
Medical Clinical and
Product Device Related Protection / Environment
Administration Records Surgical Decubitus Investigation
Related Incidents Behavior / Related Incidents
Related Incidents Related Related Ulcer Related Incidents
Incidents Criminal Related
Incidents Incidents
Incidents

Incident Reports Summary

To discussed in the Risk Management committee meetings and attached to meeting minutes

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Serial Location
Time Probabilit Severit Natur Summary Care/ Service
Date of in which the SAC Contributing Preventive Action
numbe event
of
incident
y of y
Score
e of description of Delivery Problem
Factors Taken/Planned
r event recurrence (Actual) event the incident (s)
occurred

DD /
MMM /
YYYY

DD /
MMM /
YYYY

DD /
MMM /
YYYY

Attach the Action plan for recommended corrective actions

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 Indicators
Deliverables
How to measure Required Start Responsible Contributing
effectiveness of Evidence of End Date Needed Actions
Resources Date Person Factors
the corrective completion
action