Criticisms and Suggestions

Voluntary Reporting Of Medical Errors And Accidents Form

Dear colleagues, this form is designed for reporting any incidents involving you or others. The primary goal of reporting errors is to prevent their recurrence, without attributing any blame or punishment, The information collected will be shared with relevant parties anonymously, excluding the identity of the person submitting the report or the people involved, In order to prevent duplication of those accidents and errors as well as to serve as a documented record of such experiences for future reference

Patient Characteristics

Patient FullName

Age

Gender

Name Of Attending Doctor

Date Of Admission

Case Number

Diagnosis

Name Of Ward

توضیحات

Please Mark The Severity Of The Event By The Following Categories

نزدیک به وقوع خطا ( تا آستانه وقوع پیش رفته ولی خطا رخ نداده است) : Near Missed بدون آسيب واضح:No Harm آسيب موقت، افزايش سطح مراقبت و نياز به مداخله سر پايي: Harm آسيب موقت، افزايش سطح مراقبت و افزايش طول مدت بستري: Harm-Sentinel Event آسيب دائمي: Sentinel Event مرگ: Sentinel Event

A Complete Description Of The Event Or Error That Occurred (Please State In Detail How The Error Occurred, And If Necessary Laboratory, Radiological, Etc Documentation Is Required, Please Attach A Report):
Factors And Conditions Leading To Events And Problems Caused By Them:
Summarize The Remedial Measures And Interventions And Remedial Measures Taken In This Regard:

Name Of Informant

Image Text