Clinical Incident Form – Chemo At Home

Ensure medical records are factual and up to date before completing this form.

Please ensure information included on this form is FACTUAL and DOES NOT BLAME OR IDENTIFY staff associated with the clinical incident. Information provided on the Clinical Incident Form is NOT protected by qualified privilege.

INCIDENT NOTIFICATION (to be completed by notifier) Please refer to prompts in the areas when completing this form.

View Health - chemo@home state/hub: *

Place of clinical incident (Where did the clinical incident occur?) *
Specific location e.g. patient's home, toilet, dining room, bedroom, driveway

Patient details: *
First
Last

Name *
First
Last

DOB: *//

Country of birth: *

Identifies as ATSI

Sex: *
Male
Female

Specialty *
Oncology
Haematology
Gastroenterology
Other

Date of clinical incident: *//

Time of clinical incident: *

Current and relevant diagnoses/problems: *

Was a Medical Practitioner notified? *

Has the clinical incident been documented in the patients health record? *

Was the patient informed of the clinical incident? *

Was the next of kin/guardian notified? *

Definition: A clinical incident is an event or circumstance resulting from health care which could have, or did lead to unintended and/or unnecessary harm to a patient/consumer and includes near misses. Some examples or clinical incidents to report:
• Medication error e.g. Omission or overdose

• Complications of anaesthetic management

• Infection control breach

• Fetal complications unrelated to congenital abnormality, unanticipated and/or not managed in an appropriate or timely manner

• Complications of surgery

• Unexpected death of a mental health patient

• Delayed patient transfer / transport

• Documentation incomplete/inaccessible

• Misdiagnosis & subsequent management

• Falls

• In service acquired pressure ulcers

• Delay in recognising/responding to clinical deterioration.

• Wrong patient/ body part or side

• Delayed treatment, assessment and/or diagnosis

• Patient/Consumer absconding

• Equipment or therapeutic device problems

• Self harm

• Complications of resuscitation

• Hospital process issues

• Verbal/physical aggression by a mental health client

• Provide objective information of the known facts of the clinical incident

• Avoid statements that blame or identify individuals

• Avoid second guessing what might have happened or might have caused the clinical incident

• DO NOT include staff member names but DO include their designation

Describe the actual or potential clinical incident
Please include the immediate response/action and outcome. Explain what happened, how did this clinical incident lead to injury, and which objects or substances were involved. For medication incidents state all drugs involved.

Treatment/Investigations required as a result of the clinical incident:
E.g. x-ray, blood test, ECG, EEG, dressings, new medications, referral for review by other clinician.

Notifier's details: (Clinical incident notifications can be made anonymously) *
First
Last

Medical practitioner's examination of patient:

The person who is signing off on this clinical incident ????? *
First
Middle
Last