Healthcare Error Review

Healthcare Error Review

Patient Name:    Medical Record No.:

Date of Birth:    Incident Date:    Incident Time:

Patient Information

Insurance Information

Incident Summary

Location of Incident:    Staff Involved (names / roles):

Immediate Actions Taken

Immediate clinical interventions performed:

Harm and Outcome Assessment

Level of Harm (select all that apply):

No harm observed
Minor harm (temporary, no intervention required)
Moderate harm (required additional treatment)
Severe harm (permanent injury or prolonged hospitalization)

Root Cause and Contributing Factors

Contributing factors (check all that apply):

Communication breakdown
Staffing or workload
Equipment failure or unavailability
Process or protocol deficiency
Inadequate training or competency
Documentation or medication label issue
Other (specify below)

Corrective Actions and Prevention Plan

Notifications and Disclosures

Parties notified of the event (check and provide date notified):

Patient notified   Date:
Family / Representative notified   Date:
Risk Management notified   Date:
Regulatory or licensing body notified   Date:

Patient Rights and Acknowledgement

The facility representative has explained the facts known about the event, the assessment of harm, and the proposed corrective actions. The patient or authorized representative's selection below indicates acknowledgment of receipt of this information and understanding of the following statements:

I understand the facts of the event as presented.
I understand the immediate actions taken and the planned corrective actions.
I understand that signing this review is not a waiver of any legal rights and does not prevent me from seeking further review or making a complaint.
I authorize facility staff to contact me regarding follow-up and corrective action progress.

Administrative Record

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