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    Nedle Stick Injury Format

    Uploaded by

    Chandrasree

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Nedle Stick Injury Format

    Uploaded by

    Chandrasree
    30 views3 pages

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    30 views3 pages

    Nedle Stick Injury Format

    Uploaded by

    Chandrasree

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    INCIDENT REPORTING FORM

    NEEDLE STICK AND INJURY REPORT

    1. Name :
    2. Age:
    3. Gender: female/ male
    4. Department:
    5. Date of injury: time of injury
    6. Type of sharp:
    7. Job classification of the injured person
    8. Type of location where sharps injury occurred
    9. When did the injury occur
    10. Before After During the purpose
    11. Involved body part:
    12. Was the injured person wearing glove
    13. Had the injured person completed hepatitis b vaccination series
    14. Was there a sharp container readily available for disposal of the sharp
    15. Had the injured person received training on the exposure control plan
    16. Was any immediate action taken
    17. Was the injury superficial moderate severe
    18. Was the injury exposed to any infection HIV HCV other
    19. Corrective action

    20. Counseling

    21. Post exposure prophylaxis

    22. Titer results


    INCIDENT REPORTING FORM

    Form No :
    SUDHA HOSPITAL

    INCIDENT REPORT FORM


    Form Date :

    Patient Name : Patient ID :


    Age/ Gender : IPD NO :
    Room No :

    Name of person involved :

    Designation : Department :

    Date of occurrence : Time : Exact location :

    Type of incident :

    Explain the incident in details (Attach details report that may have contributed to the incident)

    Fact behind the incident :

    Corrective / preventive action to avoid such type of accident / incident in future

    Reported by : Date :
    Designation : Time :
    INCIDENT REPORTING FORM

    INCIDENT REPORTS

    MEDICATION ERROR

    Type of error

    1. Dosage error
    2. Dose – preparation error
    3. Wrong time error
    4. Wrong rate of administration error
    5. Wrong administrative technique error
    6. Wrong patient error
    7. Un prescribed error

    1 Details of the error with date and time

    Signature

    2 Underlying cause

    Signature
    __________________________________________________________________________________
    3. Immediate action

    Signature

    4 corrective Action

    Signature
    _______________________________________________________________________________________
    5 Verification of the corrective action
    Signature

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