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Royal Children’s Hospital

Incident Report Form
Clinical Support Services

Please make certain any persons involved are safe and ensure every effort is made to treat persons involved and prevent injury to
others. This report is to be only completed if it involves patient / visitor or equipment / property. If you would like to provide an
anonymous report please don’t write any identifying details and send directly to Clinical Support Services. Please document incident
details and follow-up care in the patient’s medical record.
There is a separate form for staff incidents please contact HR.

Date: Time: Please use 24 hour clock

o Inpatient o Outpatient o Visitor o Equipment/property

Name of witness / first person to attend: o Staff o Patient o Visitor
Ward/Dept: Exact Location: Medical Team:
Patient’s Admission Diagnosis:
Medication Incident o Non-medication Incident o
Description of what happened Brief description of the incident including the immediate actions and outcome. Also document in medical record. Objective information only.

Immediate actions and outcome:

Contributing Factors Consider system, staff, patient and visitor issues - did any of these contribute to the incident. What occurred before the incident?

Prevention Ideas of how this could have been prevented

Next of kin / guardian notified / patient? o Yes o No o N/A

Medical staff notified? o Yes o No o N/A
Reported By: Other Persons involved:
Print Name Position: Print Name Position

Contact No: Contact No:

Medical Report Document patient’s assessment and list investigations and treatments. Also document in medical record. Objective information only.

Doctor’s Name:
Print Name Designation: Date/Time:

For further copies go to Clinical Support Services Website www.rch.org.au/css/ Version 2 June 2004
 Staff Member responsible for area at time of incident eg Associate Unit Manager, Registrar

Has the incident been documented in the medical record? o Yes o No o N/A
Name:
Print Name Designation: Date/Time:

Unit Manager or Department Head Ensure the form is adequately completed by your staff. Document what steps have been taken to prevent reoccurrence.

Outcome: o 1. Potential for harm, dangerous state but no event

o 2. Potential for harm, dangerous state and event intercepted
o 3. No adverse outcome
o 4. Minor outcome Medical review, extra observations or monitoring
o 5. Moderate outcome Point four plus minor diagnostic investigations or treatments eg blood test, urinalysis, first aid treatment
o 6. Mod/significant outcome Treatment with another drug, surgical intervention/cancellation, transfer to another
area with no increase length of stay
o 7. Significant outcome Hospital admission or increased length of stay/ morbidity which continued at discharge
o 8. Severe outcome Permanent disability or contributed to the patient’s death
Did the incident occur in or are another unit/department responsible for incident? o Yes o No
If yes please send form to the appropriate Unit/Department Head for comment below
Name:
Print Name Designation: Date/Time:

Unit / Department where incident occurred (If different from reporting department) Document what steps have been taken to prevent reoccurrence.

Name:
Print Name Designation: Date/Time:

For further copies go to Clinical Support Services Website www.rch.org.au/css/ Version 2 June 2004