The Patient Safety Incident Reporting Form serves as a crucial tool in maintaining and improving patient safety standards within Nigerian healthcare facilities. This document should be used whenever a patient safety incident, near-miss, or adverse event occurs in a healthcare setting. It captures essential information including incident details, immediate actions taken, patient outcomes, and notification requirements. The form is designed to comply with Nigerian healthcare regulations, particularly the National Health Act 2014 and the National Policy on Patient Safety in Healthcare Facilities. It supports healthcare providers in meeting their legal and professional obligations while facilitating systematic incident analysis and prevention strategies. The document is structured to ensure thorough documentation while remaining accessible to all healthcare workers, supporting both immediate incident management and longer-term quality improvement initiatives.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Your data doesn't train Genie's AI
You keep IP ownership of your docs
1. Reporter Information: Details of the person reporting the incident, including name, role, department, and contact information
2. Patient Information: Patient's demographic information, medical record number, and relevant clinical details (while maintaining confidentiality)
3. Incident Details: Date, time, location, and type of incident, including a clear description of what happened
4. Severity Assessment: Initial assessment of the incident's severity using standardized classification criteria
5. Immediate Actions Taken: Description of immediate steps taken to address the incident and ensure patient safety
6. Persons Involved: List of all healthcare workers and others involved in or witnessing the incident
7. Patient Outcome: Impact on the patient and their current condition following the incident
8. Notification Details: Record of who was notified about the incident (supervisors, specialists, family members)
9. Initial Risk Assessment: Preliminary evaluation of the risk level and potential for recurrence
1. Equipment Details: Used when the incident involves medical equipment or devices, including make, model, and serial numbers
2. Medication Details: Specific section for medication-related incidents, including drug names, doses, and administration details
3. Environmental Factors: Description of environmental conditions that may have contributed to the incident
4. Staff Impact Assessment: Section for documenting impact on staff when the incident affects healthcare workers
5. Witness Statements: Additional detailed statements from witnesses when multiple perspectives are needed
6. Communication Record: Detailed log of communications with family members or other healthcare providers regarding the incident
1. Severity Classification Guide: Reference guide for standardized severity assessment criteria
2. Incident Category Definitions: Detailed definitions and examples of different types of patient safety incidents
3. Reporting Flowchart: Visual guide showing the incident reporting and escalation process
4. Risk Matrix: Tool for assessing and categorizing risk levels
5. Required Notification Checklist: List of parties to be notified based on incident type and severity
6. Follow-up Action Template: Template for documenting required follow-up actions and investigations
Find the exact document you need
Patient Safety Incident Reporting Form
A standardized form for reporting patient safety incidents in Nigerian healthcare facilities, aligned with national healthcare regulations and reporting requirements.
Download
Health And Safety Incident Report Form
A standardized form for documenting workplace health and safety incidents in Nigeria, ensuring compliance with local regulations while facilitating incident investigation and risk management.
Download
Hazard Report Form
A standardized hazard reporting form for Nigerian workplaces, ensuring compliance with local safety regulations while facilitating efficient hazard documentation and response.
Download
Hazard Incident Report Form
A standardized form for documenting workplace hazards and incidents in Nigeria, compliant with local labor and safety regulations.
Download
Employee Incident Report Form
A comprehensive workplace incident reporting form compliant with Nigerian labour laws and safety regulations, used to document and investigate workplace incidents.
Download
Critical Incident Report Form
A standardized Nigerian-compliant form for documenting and reporting significant incidents, accidents, or near-misses in workplace settings.
Download
Security Incident Report Form
A standardized form for documenting and reporting security incidents in compliance with Nigerian regulations, designed to capture essential incident information and response measures.
Download
Incident Response Form
A Nigerian-compliant incident response documentation template for recording and managing security incidents and data breaches in accordance with NDPR and local regulations.
Download
Incident Investigation Form
A standardized form for investigating and documenting workplace incidents in compliance with Nigerian safety regulations and reporting requirements.
Download
Genie’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; Genie’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it