HEALTHCARE INCIDENT REPORTING CHECKLIST: INVESTIGATION & RESOLUTION

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--- INITIAL REPORT & DOCUMENTATION ---
[ ] Date of Incident
[ ] Time of Incident
[ ] Brief Description of Incident
[ ] Initial Suspected Cause (Equipment Failure, Human Error, Communication Breakdown, Environmental Factors, Unknown)
[ ] Location of Incident
[ ] Number of Patients Involved
[ ] Reporting Staff Name
[ ] Signature of Reporting Staff

--- INCIDENT CATEGORIZATION & SEVERITY ASSESSMENT ---
[ ] Incident Category (Patient Safety, Operational, Security, Regulatory, Property Damage, Workplace Injury)
[ ] Severity Level (Low, Moderate, High, Critical)
[ ] Estimated Cost of Damage (USD)
[ ] Brief Description of Incident
[ ] Date of Incident
[ ] Time of Incident

--- INVESTIGATION TEAM FORMATION & ASSIGNMENT ---
[ ] Incident Investigator Lead (Clinical Director, Risk Manager, Department Head, Quality Assurance Specialist)
[ ] Investigator 2 (Clinical Expertise) (Physician, Nurse, Pharmacist, Therapist)
[ ] Investigator 1 (Documentation & Compliance) (Legal Counsel, Compliance Officer, Records Manager)
[ ] Investigation Start Date
[ ] Brief Description of Team Member Roles
[ ] Reporting Structure - Who does the Investigation Lead report to? (Hospital Administrator, Medical Executive Committee, Risk Management Committee)

--- DATA GATHERING & EVIDENCE COLLECTION ---
[ ] 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) (Medical Records, Policies and Procedures, Incident Reports, Training Records)
[ ] Number of Witnesses Involved
[ ] Summary of Witness Statements
[ ] Precise Location of Incident

--- ROOT CAUSE ANALYSIS ---
[ ] Detailed Description of the Incident Sequence of Events
[ ] Potential Contributing Factors (Select all that apply) (Human Error, Equipment Failure, Communication Breakdown, Process Deficiencies, Training Gaps, Environmental Factors)
[ ] Primary Root Cause Category (Systemic, Individual, Environmental)
[ ] 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 (Policy A, Procedure B, None Applicable)

--- CORRECTIVE ACTIONS & IMPLEMENTATION ---
[ ] Detailed Description of Corrective Action(s)
[ ] Estimated Cost of Corrective Action(s)
[ ] Planned Implementation Date
[ ] Responsible Department for Implementation (Nursing, Medical Records, Pharmacy, Administration, Other)
[ ] Affected Policies/Procedures Requiring Updates (Policy A, Policy B, Procedure X, Procedure Y)
[ ] Supporting Documentation (e.g., Revised Policies)
[ ] Completion Date of Implementation

--- VERIFICATION OF CORRECTIVE ACTIONS ---
[ ] Date of Verification
[ ] Verification Method (Direct Observation, Document Review, Interview, Audit)
[ ] Number of Observations/Samples Verified
[ ] Detailed Verification Findings
[ ] Effectiveness of Corrective Actions (Fully Effective, Partially Effective, Not Effective)
[ ] Verifier Signature
[ ] Additional Comments / Notes

--- REPORTING & COMMUNICATION ---
[ ] Reporting Method Used (Email, Paper Form, Incident Management System, Other)
[ ] Summary of Findings (Brief Description)
[ ] Recipient(s) Notified (Risk Manager, Department Head, Legal Counsel, Executive Leadership)
[ ] Date of Report Submission
[ ] Time of Report Submission
[ ] Communication Log (Details of discussions/updates)

--- TREND ANALYSIS & CONTINUOUS IMPROVEMENT ---
[ ] Total Number of Incidents Reported (Last 12 Months)
[ ] Percentage Change in Incident Rate (Compared to Previous Period)
[ ] Recurring Incident Categories (Medication Errors, Falls, Infection Control, Communication Breakdown, Equipment Malfunction)
[ ] Summary of Key Trends Identified
[ ] Date of Last Review Meeting
[ ] Action Items Agreed Upon for Process Improvement
[ ] Overall Assessment of Improvement Efforts (Significant Improvement, Moderate Improvement, Minimal Improvement, No Improvement)

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