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Patient Safety Incident Report Form

Patient Safety Incident Reports can be completed by Paramedics, Management or others wishing to report a concern or variance. Please complete in as much detail as possible to provide context for full analysis. Note: please don’t include any patient health information (PHI) in your responses.

Definitions

Patient Safety Incident: an event that resulted in unintended harm to the patient and which is related to the care or services provided rather than the patient’s underlying condition.

Good Catch/ Near Miss: An event or error that could have caused harm but did not reach the patient because of a timely intervention or apparent good future.

Hazard A set of circumstances or a situation that could cause harm or injury to a patient. A hazardous situation was identified with no patient involvement.

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Please concisely describe the patient safety issue and the any relevant background or context information to the incident.

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Please enter your EHSN in the appropriate box if available
Please enter your EHSN in the appropriate box if available
Click Submit to complete this form

The information gathered is used by the RPPEO to help us improve process and identify potential issues through the quality process in place. This information is also shared with your service.

If you indicated that you would like someone to follow up with you, please allow us up to 2 weeks to respond.

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