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Patient Safety Incident Reporting Form

Patient Safety Incident Reporting Form Template for Canada

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Key Requirements PROMPT example:

Patient Safety Incident Reporting Form

"I need a Patient Safety Incident Reporting Form for our multi-location hospital network in Ontario, with special emphasis on medication errors and device malfunctions, that can be completed both electronically and in paper format."

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Document background
The Patient Safety Incident Reporting Form is a crucial document used across Canadian healthcare facilities to document and report any incidents that affect or could affect patient safety. This form must be completed whenever a patient safety incident, near-miss, or adverse event occurs within a healthcare setting. It captures essential information including incident details, immediate actions taken, severity assessment, and follow-up measures required. The form is designed to comply with Canadian federal and provincial healthcare regulations, including the Patient Safety Act, provincial health information privacy laws, and healthcare facility policies. It serves multiple purposes: documenting incidents for legal and administrative requirements, facilitating quality improvement initiatives, and contributing to broader patient safety data collection and analysis efforts.
Suggested Sections

1. Reporter Information: Details of the person reporting the incident, including name, role, department, and contact information

2. Patient Information: Basic patient demographics and identifiers (while maintaining privacy requirements)

3. Incident Details: Date, time, location, and type of incident

4. Incident Description: Detailed narrative of what occurred, including sequence of events

5. Immediate Actions Taken: Steps taken immediately following the incident to address patient safety

6. Severity Assessment: Assessment of actual and potential harm using standardized severity scales

7. Contributing Factors: Identification of factors that may have contributed to the incident

8. Notifications Made: List of individuals/departments notified about the incident

9. Witness Information: Details of any witnesses to the incident

10. Declaration: Reporter's declaration of accuracy and signature section

Optional Sections

1. Medical Device Details: Used when incident involves medical equipment or devices

2. Medication Details: Used for medication-related incidents, including medication names, doses, and routes

3. Staff Injury: Used when staff members were also injured during the incident

4. Environmental Factors: Used when physical environment contributed to the incident

5. Family Notification: Used when family/next of kin have been informed of the incident

6. Patient Status Update: Used for tracking patient condition post-incident

7. Security Involvement: Used when security personnel were involved in the incident

Suggested Schedules

1. Severity Assessment Scale: Standardized scale for assessing incident severity and potential harm

2. Incident Classification Guide: Guide for categorizing different types of patient safety incidents

3. Reporting Guidelines: Detailed instructions for completing each section of the form

4. Notification Matrix: Guide indicating who should be notified based on incident type and severity

5. Follow-up Action Checklist: Checklist of required actions following different types of incidents

6. Related Policies Reference: List of organizational policies relevant to incident reporting and management

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok³ÉÈË°æ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions






























Clauses




















Relevant Industries

Healthcare

Hospital Administration

Primary Care

Long-term Care

Mental Health Services

Emergency Medical Services

Rehabilitation Services

Diagnostic Services

Pharmaceutical Services

Public Health

Relevant Teams

Quality Assurance

Risk Management

Patient Safety

Clinical Operations

Nursing Administration

Medical Staff Office

Pharmacy

Emergency Services

Regulatory Compliance

Legal Affairs

Clinical Education

Hospital Administration

Information Management

Professional Practice

Relevant Roles

Registered Nurse

Physician

Pharmacist

Healthcare Administrator

Quality and Safety Manager

Risk Management Officer

Department Head

Clinical Director

Patient Safety Officer

Unit Manager

Medical Laboratory Technologist

Respiratory Therapist

Emergency Medical Technician

Social Worker

Occupational Therapist

Physical Therapist

Clinical Nurse Specialist

Nurse Practitioner

Healthcare Risk Analyst

Patient Safety Coordinator

Industries








Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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