Neurosurgical Incident Report Form Template

Basic Information

• Date and Time of Incident: [DD/MM/YYYY] [HH:MM]
• Location: □ OR □ ICU □ Ward □ Other: _______
• Patient Identifier: _______________
• Procedure (if applicable): _______________

Incident Classification

□ Near Miss □ Adverse Event □ Sentinel Event □ Equipment Malfunction □ Medication Error □ Other: _______

Incident Details

Type of Event

□ Wrong-site surgery □ CSF leak □ Surgical site infection □ Neurological deficit □ Hemorrhage □ Equipment-related □ Other: _______

Severity Assessment

□ No harm □ Mild harm □ Moderate harm □ Severe harm □ Death

Description

Incident Narrative

Provide detailed description of the event:

Immediate Actions Taken

Contributing Factors

□ Communication issues □ Equipment/device factors □ Environmental factors □ Staff factors □ Patient factors □ Organizational factors

Follow-up Actions

Required Notifications

□ Department Head □ Risk Management □ Patient Safety Officer □ Legal Department

Preventive Measures

Reporter Information

• Name: _______________
• Role: _______________
• Contact: _______________
• Signature: _______________
• Date: _______________

Review Section

Department Head Review

• Comments: _______________
• Action Required: □ Yes □ No
• Signature: _______________
• Date: _______________