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Performance
Clinical Incident Report
This form is used to report clinical incidents to the Performance Improvement Committee.
This report will be sent to the PI Committee members only.
Date and Time of Report
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Person Reporting
Required
Department or Agency
Crew Member 1
Crew Member 2
Student / Rider
Others present:
Date and Time of Incident
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Call or Incident Number
Category
Required
Medication Issue (Under or Overdose)
Treatment Decision Question (Did I do the right this? Should I have done more?)
Acting Outside of Protocols (I did the right thing for the patient and got , or did not get medical direction)
Destination Decision
Hospital Staff Interactions
Location of Incident
Required
Description of Incident
Required
Email of person reporting
Required
Submit