Sharps and Needlestick Injury

Incident Reporting Form

www.quasrapp.com

Questions Answers

Brief description of the event

(Include: Date, Time & Location)

What initial actions were taken?

Name of staff affected by the incident

Occupation of the involved staff [ ] Doctor

[ ] Nursing Staff
[ ] Laboratory Staff
[ ] Pharmacy Staff
[ ] Housekeeping Staff
[ ] Nursing/Medical Student or Intern
[ ] Other Clinical Staff - Please Specify:
[ ] Other Non-Clinical Staff - Please Specify:

Select the type of device involved in the NSI [ ] Needle

[ ] Suture Needle
[ ] Spinal or Epidural Needle
[ ] Scalpel Blade
[ ] Lancet
[ ] IV Stylet
[ ] Other - Please Specify:

Purpose for which the device was being used [ ] Medication preparation
[ ] Administering medication/vaccine
[ ] Venepuncture
[ ] Cannulation
[ ] Surgical procedure
[ ] Diagnostic procedure
[ ] Blood sugar monitoring; glucometer
[ ] Other - Please Specify:

Was the device sterile or contaminated? [ ] Sterile

*Contaminated: Exposed to blood/body fluid of a patient [ ] Contaminated
[ ] Unknown

Are the source of contamination known? (Patient Details) [ ] Known

[ ] Unknown

Provide patient details [ ] Name

[ ] MRN/ID No.
[ ] Department
[ ] Diagnosis
[ ] Doctor

Was medical treatment provided? [ ] Yes

[ ] No
[ ] Refused

What was the outcome of the incident? [ ] Medical Leave

[ ] Hospitalization
[ ] Fatality
[ ] None
[ ] Other - Please Specify:

Remarks
 QUASR - Healthcare Incident Reporting Software
(+65)94883428 | hak@healthgrc.com | www.quasrapp.com
Try Digital Incident Reporting Today! >>