Question

case study: using the incident report form

A patient John Doe is a year ol. He received several required immunization including an influenza injection. The nurse gave the patient a double dose. This would be a patient error incident report.

Incident Report Form

Type of Incident (Circle One):    Patient / Employee Facility/Clinic: _________________________________

Date of Incident __________  Time of Incident: ________ am/pm

Name of Person(s) affected by incident: _______________________________ Location in Facility/Clinic where incident occurred: ____________________________________________________________ Name of Person(s) involved/witnessing Incident: ______________________________________________________________ _____________________________________________________________________________________________________ Name, Address,  Telephone Number of  Witness(es)* _____________________________________________________________________________________________________ __________________________________________________________________________________________________                                                                                                                                                                              ___ Facility/Clinic Director Name: ____________________________ Date Risk Management Notified: _________

Details of Incident. Please write legibly and be very specific. (Attach additional sheets as needed.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Did this incident result in an injury? (Circle one)    Yes / No         Type of Injury: ________________ Location: _____________ Action Taken: _________________________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Is there any further follow up required? ______________________________________________________________________ _____________________________________________________________________________________________________ For Patient Incidents ONLY – How did patient, family, and facility react to incident? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Incident Reported To:____________________________________________________________

     I hereby attest that the facts stated herein are true to the best of my knowledge.

                                                                                                                                                                                    

Completed by (Please Print)                                                            Signature                                                            Date

                                                                                                            

__________________________________________                        _____________________________________________

RTL/Clinic Director          (Please Print)                                           Signature                                                            Date                                                                                                                                                                              

Answer 1

Type of incident - Employee

Facility / clinic - clinic

Name of the person affected by incident - John Doe

Location in the facility /clinic where incident occurred - immunization room

Name of the person who witnessed - another nurse

Address ,telephone number of witness - another nurse address and telephone number

Facility / clinic director name - name of the director of clinic

Date risk management notified - the date when incident report is being filled

Details of incident - John doe is a one year old patient who came for the immunization in the clinic . While giving the immunization dose ,the nurse mistakenly gave double dose to the patient and it was witnessed by another nurse on duty.

Did this incident result in injury - yes

Type of injury - allergic reaction

Location - clinic

Action taken - Administration of injection avil and hydrocortisone .

Is there any further follow up required - yes

For patient incident only - patient is so small in age that he was unable to express while he had allergic reaction to the mistake done by the nurse and his parents were angry towards the nurse and the administration of the clinic

Incident reported to - Incident / hazard management team

I hereby attest that the facts stated herein are true to the best of my knowledge .

Completed by : Name of the staff

Signature

Date

Clinic director : Name   

Signature

Date