Healthcare Incident Reporting Checklist: Investigation & Resolution
Streamline incident investigations & ensure compliance. Our Healthcare Incident Reporting Checklist guides you through every step, from initial reporting to final resolution, minimizing risks & improving patient safety. Download now & enhance your healthcare operations!
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Initial Report & Documentation
Capturing the immediate details of the incident.
Date of Incident
Time of Incident
Brief Description of Incident
Initial Suspected Cause
Location of Incident
Number of Patients Involved
Reporting Staff Name
Signature of Reporting Staff
Incident Categorization & Severity Assessment
Determining the type and potential impact of the incident.
Incident Category
Severity Level
Estimated Cost of Damage (USD)
Brief Description of Incident
Date of Incident
Time of Incident
Investigation Team Formation & Assignment
Identifying and assigning responsibility to investigation personnel.
Incident Investigator Lead
Investigator 2 (Clinical Expertise)
Investigator 1 (Documentation & Compliance)
Investigation Start Date
Brief Description of Team Member Roles
Reporting Structure - Who does the Investigation Lead report to?
Data Gathering & Evidence Collection
Systematically collecting relevant information and documentation.
Date of Incident
Time of Incident
Detailed Description of Incident (Witness Accounts)
Supporting Documentation (Photos, Videos, Charts)
Type of Documentation Reviewed (e.g., Medical Records, Policies)
Number of Witnesses Involved
Summary of Witness Statements
Precise Location of Incident
Root Cause Analysis
Identifying the underlying factors that contributed to the incident.
Detailed Description of the Incident Sequence of Events
Potential Contributing Factors (Select all that apply)
Primary Root Cause Category
Explanation of How the Selected Root Cause Led to the Incident
Number of Similar Incidents in the Past Year
Existing Policies/Procedures Relevant to the Incident
Corrective Actions & Implementation
Developing and putting in place measures to prevent recurrence.
Detailed Description of Corrective Action(s)
Estimated Cost of Corrective Action(s)
Planned Implementation Date
Responsible Department for Implementation
Affected Policies/Procedures Requiring Updates
Supporting Documentation (e.g., Revised Policies)
Completion Date of Implementation
Verification of Corrective Actions
Ensuring the implemented actions are effective.
Date of Verification
Verification Method
Number of Observations/Samples Verified
Detailed Verification Findings
Effectiveness of Corrective Actions
Verifier Signature
Additional Comments / Notes
Reporting & Communication
Documenting findings and communicating with stakeholders.
Reporting Method Used
Summary of Findings (Brief Description)
Recipient(s) Notified
Date of Report Submission
Time of Report Submission
Communication Log (Details of discussions/updates)
Trend Analysis & Continuous Improvement
Monitoring incident patterns and refining processes.
Total Number of Incidents Reported (Last 12 Months)
Percentage Change in Incident Rate (Compared to Previous Period)
Recurring Incident Categories
Summary of Key Trends Identified
Date of Last Review Meeting
Action Items Agreed Upon for Process Improvement
Overall Assessment of Improvement Efforts
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