INCIDENT REPORTING FORM

NEEDLE STICK AND INJURY REPORT

1. Name :
2. Age:
3. Gender: female/ male
4. Department:
5. Date of injury: time of injury
6. Type of sharp:
7. Job classification of the injured person
8. Type of location where sharps injury occurred
9. When did the injury occur
10. Before After During the purpose
11. Involved body part:
12. Was the injured person wearing glove
13. Had the injured person completed hepatitis b vaccination series
14. Was there a sharp container readily available for disposal of the sharp
15. Had the injured person received training on the exposure control plan
16. Was any immediate action taken
17. Was the injury superficial moderate severe
18. Was the injury exposed to any infection HIV HCV other
19. Corrective action

20. Counseling

21. Post exposure prophylaxis

22. Titer results

 INCIDENT REPORTING FORM

Form No :
SUDHA HOSPITAL

INCIDENT REPORT FORM

Form Date :

Patient Name : Patient ID :

Age/ Gender : IPD NO :
Room No :

Name of person involved :

Designation : Department :

Date of occurrence : Time : Exact location :

Type of incident :

Explain the incident in details (Attach details report that may have contributed to the incident)

Fact behind the incident :

Corrective / preventive action to avoid such type of accident / incident in future

Reported by : Date :
Designation : Time :
 INCIDENT REPORTING FORM

INCIDENT REPORTS

MEDICATION ERROR

Type of error

1. Dosage error
2. Dose – preparation error
3. Wrong time error
4. Wrong rate of administration error
5. Wrong administrative technique error
6. Wrong patient error
7. Un prescribed error

1 Details of the error with date and time

Signature

2 Underlying cause

Signature
__________________________________________________________________________________
3. Immediate action

Signature

4 corrective Action

Signature
_______________________________________________________________________________________
5 Verification of the corrective action
Signature