Incident Report Template - PDF Templates

E-INCIDENT AND NEAR MISS REPORTING NOTIFICATION FORM

Item - Incident Report Template Image-1 0

IR NUMBER:

IR-DEC2024/0078

PART 1: INCIDENT AND NEAR MISS INFORMATION

DATE & TIME OF REPORTING:

6 December 2024 06:25 AM

DATE & TIME OF THE EVENT:

Friday, December 6, 2024 05:30

TYPE OF EVENT:

Incident

PARTY INVOLVED:

Patient Related

IF PATIENT INVOLVED:

Patient Name: TEO GUAT CHOO Patient PRN: 2028738 Gender: Female Ward / Clinic / Department: Ward 6 Doctor: Prof Dr Azhar & Dr Lee Li Ching

FULL NARATIVE OF T

HE EVENT (INCIDENT

/ NEAR MISS):

Patient Name: MADAM TEO GU

AT CHOO

Patient PRN: 2028738

Gender: FEMALE

Ward / Clinic / Department

: WRAD 6

Doctor: Prof Azhar and DR

LEE LC

Incident Report: Fall Inci

dent - Room 626

Date: 6/12/2024

Time: 0530Hrs

Summary of Events:

Assisted the patient to th

e toilet using a walking f

rame. The patient is depen

dent but able to ambulate

with support. Patients wan

t to wash hand with the do

or was open. Patient insis

t want SN to wait outside

the toilet. Patient attemp

ted to stand and hold walk

ing frame and with the one

hand want to wash the han

d but suddenly fall backwa

rds to the floor in a sitt

ing position and the head

hit on the wall Immediatel

y after the fall, SN Aziat

ul lifted the patient and

bring to the bed. Noted He

matoma seen at scalp regio

n. but no bleeding seen.

Ice pack applied at the sw

ollen part.

Post-Fall Assessment:

DR Dalila and DNA Aiman we

re informed and responded

immediately

Physical examination by Dr

. Dalila:

Noted Hematoma seen at the

scalp region. but no blee

ding seen.

Patient claim pain at the

head with pain score 4/10.

GCS 15/15 with no sign of

neurological deficits. Dr

essing Osite x1 at Lt Hip

intact, old blood stained

seen

Circulation was good, skin

was warm and pink, with a

capillary refill time (CR

T) of less than 3 seconds.

Pedal pulse was strong an

d palpable.

The patient was able to mo

ve affected limbs, with no

pitting edema observed.

Vital Signs:

Blood Pressure: 155/72 mmH

g

Pulse: 79 bpm

SpO2: 96% on room air

Temperature: 36.7°C

Patient Safety Measures:

The patient was advised to

use the call bell if assi

stance is needed, and the

call bell was made easily

reachable.

All side rails were raised

.

Ongoing monitoring will co

ntinue.

Recommendation:

Dr. Dalila advised continu

ed observation and GCS mon

itoring

For CT Brain . Withold Asp

irin now

to observe for signs and s

ymptoms of concussion (vom

iting, reduce LOC, visual

disturbances)

continue cold compression

on the hematoma

The patient was advised to

use the call bell if assi

stance is needed, and the

call bell was made easily

reachable

All side rails were raised

Ongoing monitoring will co

ntinue

Additional Notes:

Prof Azhar and Dr Lee LC w

ere informed and acknowled

ged the incident

A post-fall huddle was con

ducted and raised

REPORTING BY (STAFF NAME):

AZIATUL ATIKA BINTI BUYONG

DESIGNATION:

STAFF NURSE

EVENT LOCATION:

Ward 6- Room 627

DEPARTMENTAL EMAIL:

ward@altyortho.com

Income Verification Letter Template

Contract Termination Letter

Letter of Recommendation for Scholarship

Early Lease Termination Letter

Resignation Confirmation Letter

Job Confirmation Letter