Clinical Incident and Hazard Report Form
v2.1
Purpose. Staff use this form to report any clinical incident, near miss, medication error, hazard, injury or privacy breach so that it is entered into the Clinical Incident and Hazard Register and reviewed.
1.When to use this form
Complete this form for any event that harmed or could have harmed a patient, staff member or visitor, including wrong patient, wrong medicine, a failed steriliser load, a specimen labelling error, a fall, a needlestick, a cold chain breach or a privacy breach. Complete it before the end of your shift. Make the patient and area safe first.
2.Who completes it
The person involved or the person who found the event completes the form. The department lead reviews the severity rating and enters the record into the register. Incidents rated 1 or 2 must be escalated to the Medical Director on the day.
3.Describing the event
Write what happened in plain words and in order. Include the patient reference (not the full name on this form), the medicines, equipment or specimens involved, and who was present. Record facts, not opinions about cause.
4.Immediate actions
Record what was done straight away: first aid, medical review, open disclosure to the patient, isolation of equipment or vaccines, quarantine of a steriliser load, or notification to the laboratory or the state immunisation program.
5.After submission
The department lead will give you the register number and tell you the outcome of the review. Findings will be shared with your team at the next practice meeting where they apply to others.