Free Medical Critical Incident Report

I. Incident Overview

A. Report Details

• Reporter Name: [Your Name]

• Reporter Email: [Your Email]

• Company Name: [Your Company Name]

• Report Date: April 15, 2050

B. Incident Summary

• Incident Date and Time: April 14, 2050, 12:30 PM

• Location: Intensive Care Unit, [Your Company Name]

• Incident Type: Medication Error

• Severity Level: Critical

II. Incident Description

A. Detailed Narrative

On April 14, 2050, at approximately 12:30 PM, Nurse Jane Smith administered an incorrect dosage of medication to Patient Robert Miller in the Intensive Care Unit. The medication involved was insulin, and the error resulted in the patient experiencing severe hypoglycemia.

B. Immediate Actions Taken

1. The error was immediately reported to the attending physician.

2. Emergency protocols were activated.

3. The patient was given intravenous glucose.

4. Continuous monitoring of the patient’s vitals was initiated.

5. The patient was stabilized within 30 minutes of the incident.

C. Contributing Factors

• Staffing Levels: Understaffed shift

• Training Issues: Recent changes in medication protocols not fully communicated

• Equipment: Malfunctioning infusion pump

III. Impact Assessment

A. Patient Outcome

• Condition Post-Incident: Patient stable but required additional monitoring

• Long-term Impact: No expected long-term effects

B. Organizational Impact

• Operational Disruption: Temporary diversion of ICU resources

• Financial Impact: Estimated cost of additional treatment: $5,000

• Reputation Impact: Potential for decreased patient trust

IV. Root Cause Analysis

A. Methodology

• Tool Used: Fishbone Diagram

• Team Members Involved:

  • Dr. Sarah Connor, Chief Medical Officer

  • Nurse Jane Smith

  • Michael J. Brewster, Risk Manager

B. Identified Root Causes

1. Human Error: Miscalculation of dosage

2. Communication Breakdown: Inadequate handoff procedures

3. Systemic Issues: Insufficient staff training on new protocols

V. Corrective and Preventive Actions

A. Immediate Corrections

• Re-training of staff on new medication protocols

• Temporary increase in ICU staffing levels

• Inspection and repair of all infusion pumps

B. Long-term Preventive Measures

1. Staff Training: Regular mandatory training sessions on protocol changes

2. Communication Improvement: Implementation of a Standard handoff checklist

3. Equipment Maintenance: Quarterly maintenance checks for all critical equipment

VI. Reporting and Follow-Up

A. Incident Report Submission

• Submitted By: [Your Name]

• Submission Date: April 15, 2050

• Contact Information: [Your Email]

B. Follow-Up Actions

• Responsible Party: Risk Management Department

• Follow-Up Review Date: May 15, 2050

• Review Findings: To be documented after the follow-up review

VII. Signatures

Report Templates @ Template.net