Voluntary Error Reporting Submition

Voluntary Reporting Of Medical Errors And Accidents Form

Dear Colleagues, Through This Form, You Can Report Any Incident In Which You Or Others Are Involved The Purpose Of Reporting Errors Is To Avoid Repeating Errors There Will Be No Punishment Or Blame From The Authorities The Information Obtained Will Be Provided To Other Interlocutors Without Mentioning The Name And Relevant Department, So As To Avoid Duplication Of Similar Cases And Serve As A Documented Experience

Patient Characteristics

نام و نام خانوادگي بيمار

Age

Sex

Name Of Attending Doctor

Date Of Admission

Case Number

Diagnosis

Name Of Ward

توضیحات

Please Mark The Severity Of The Event By The Following Categories

نزدیک به وقوع خطا ( تا آستانه وقوع پیش رفته ولی خطا رخ نداده است) : Near Missed بدون آسيب واضح:No Harm آسيب موقت، افزايش سطح مراقبت و نياز به مداخله سر پايي: Harm آسيب موقت، افزايش سطح مراقبت و افزايش طول مدت بستري: Harm-Sentinel Event آسيب دائمي: Sentinel Event مرگ: Sentinel Event

A Complete Description Of The Event Or Error That Occurred (Please State In Detail How The Error Occurred, And If Necessary Laboratory, Radiological, Etc Documentation Is Required, Please Attach A Report):
Factors And Conditions Leading To Events And Problems Caused By Them:
Summarize The Remedial Measures And Interventions And Remedial Measures Taken In This Regard:

Name Of Informant

Image Text