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Safety Incident Report (SIR)
Safety Incident Report (SIR)
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Date & Time of incident occurrence
*
Date
Time
Location of incident
*
Related departments
*
Patient experience
Physical therapy
Security
Supply chain
ER
IP
OP
OR
Recovery room
Reception
Admission office
Date & Time of reporting the incident
*
Date
Time
Who was affected in this incidents?
*
Patient
Staff
Visitor
The facility (DTMC)
Other
Affected person full name
*
First
Last
If the affected person is the patient, MRN
*
Type of Incident:
*
Actual (An event or circumstance which happened and caused actual or has the potential to cause unintended and/or unnecessary harm or injury to patients, staff, contractors, visitors, and/or organization)
Near Miss (An event or situation that could have resulted in an accident, injury, or illness but was prevented from occurring either by chance or through timely intervention)
Categories
*
Security related issues.
Behavior.
Staff related issues.
Patient Care Management.
Laboratory related issues.
Procedural.
Medical Equipment Issues.
Facility Maintenance.
Environment /Safety.
Accommodation related issues.
Information technology related issues.
Medical imaging and diagnostic procedure.
Food Services.
Clinical Nutrition.
Infection Control related issues.
Occupational Health.
Housekeeping.
Intravenous.
Pressure Ulcer (Injury).
Skin Lesions / Integrity.
Medication.
Communication Issues.
Fall.
Radiation treatment (Ionizing radiation Non-Ionizing (Us, UV, Laser, Other).
Labor and delivery related issues.
Supply Chain issues (logistics).
Laundry services.
Sentinel Events.
ID/Document/Consent.
Security related issues
*
General /Assault & Harassment
Suspected Abuse and Neglect by Healthcare provider/family
Theft and Lost
Narcotics and Dangerous Drugs
General /Assault & Harassment
*
Potential/facility property damage
Vandalism
Physical Assault
Actual or potential violent or out of control person
Verbal Assault
Inappropriate/Aggressive Behavior
Left with permission and did not return
Left with permission and returned late
Left without permission and not returned -Absconded
Left without permission and returned late
Unauthorized entry
Unauthorized usage of hospital property
Fraud
No property pass
Smoking policy violation
Unclaimed patient belongings
Public Disorder
Room locked and can’t be open
Staff not wearing badges/ Identification while in hospital premises
Poor security response
No security staff in the building
Noncompliance with visiting hours’ policy
Abusive, violent, disruptive or self- harming behavior
Breach of confidentiality
Door lock changed
Suicidal Attempt
Intended Self Harm
Physical Harassment
Verbal Harassment
Weapon Found
Suspected Abuse and Neglect by Healthcare provider/family
*
Elderly Sexual
Adult Sexual
Child sexual
Elderly Neglect
Child Neglect
Adult Neglect
Theft and Lost
*
Missing property
Narcotics and Dangerous Drugs
*
Controlled drug cabinet keys/ access issues
Controlled medication count not done
Controlled medication left unsecured
Narcotic Broken Full ampoule/vial
Controlled medication spilled
Controlled medication-broken
Controlled medication-inadvertent disposal
Duplication Medication
Behavior
*
Noncompliant/ Uncooperative/ Inappropriate Behavior
Inconsiderate/ Rude/Hostile Behavior
Discrimination/ Prejudice Behavior
Death Threat Behavior
Aggression Behavior
Disruptive behaviors
Family/sitter interfering with patient care
Staff related issues
*
Refusal to perform assigned tasks
Non-Performance of Duty/Breach of Duty
Reporting for Retaliation
Bullying
Dress Code Violation
Inappropriate/ Irresponsible Behavior
Lack Professional Development
Staff Confidentiality/ Disclosure
Unfair Dismissal
Unfair workload
Wrongful Accusation
Physician not privileged
Non-compliance with organization policy and procedure
Ethical issues
Patient care management
*
Patient Disposition
Clinical Administration
Patient Disposition
*
Delay in admitting patient
Delay in discharging patient
Delay in referral to home health care
Delay in patient transfer
Delay in transferring patient
Delay of releasing deceased body
Dispute regarding patient management
Late Patient Arrival
Unplanned / Unnecessary admission/ transfer
Unplanned return to critical care (24hrs)
Unplanned return to ED (72hrs)
Improper/Unsafe transport of patient
Appointment not entered
Delayed for appointment time
Improper patient discharge
Wrong Appointment
No/Incomplete admission orders
Admission/Encounter-Ineligible patient
Incorrect demographics
Inappropriate restraint use
Left Against Medical Advice (DAMA)
No/Incomplete discharge orders
No/Invalid consent obtained
No/incomplete transfer orders
No patient ID band
No sitter to stay with patient
Patient has more than one MRN
Patient ID band/Wrong patient
Chest tube clamped
Missed diagnosis
Critical results not acted upon
No consultation when indicated
Inadequate/incomplete assessment
Refuse Male Physician
Refuse Female Physician
Refuse to Wait for XR Result
Patient not prepared
Patient was not wearing the ID band
Patient weight / height not updated
Physician refused to attend
Possible alternative interventions not utilized
Treatment plan is not followed
Unreleased tourniquet on patient’s arm
Inadequate treatment/intervention for condition
Drowning/Near Drowning within hospital premises
Delay in arrival of physician/ surgeon
Inadequate pain management
Procedure done without GA
Clinical Administration
*
Wrong code announced
No handover provided
Handover-Inaccurate/incomplete information
Laboratory related issues
*
Delayed delivery of blood/blood products
Delayed feedback on rejected specimen
Incomplete blood/ blood products request
Critical result not reported (Lab technician did not give results to physician)
Critical result reported but physician refused to accept results
"Critical result not reported (Lab technician unable to contact physician)"
Lost sample
Wrong Patient’s MRN
Phlebotomy delayed
Transfusion reaction
Delayed Test Results
Delayed return of unused blood products
Unsuitable blood/ blood products
Wrong results
Unavailability of Blood and Blood products
Procedural
*
Pre- Procedural
During Procedural
Pre- Procedural
*
Cancelation of Surgery
During Procedural
*
Emergency Case changed to Elective by Surgeon/Physician
Incomplete procedure on Surgery Schedule
Incorrect Site/SIDE indicated on surgery schedule
Incorrect Medical Records
Incorrect PROCEDURE indicated on the surgery schedule
No Side indicated
Medical Equipment issues
*
Electrical items not tested
Home Care Equipment Issues
Medical Equipment Broken or Abuse
Medical equipment misuse
Medical device unexpected failure
Improper / missing tagging of medical equipment
Medical equipment training related issues
Delayed Response for New Medical Equipment Request.
Delivered Device is not matching the Requirements.
Poor biomedical engineering response to Emergency calls.
Medical Device PPM Over Due
Medical Device violating safety standards
Facility Maintenance
*
Heating, Ventilation, Air condition (HVAC) failure
Disruption of power supply
Failure of elevators
Medical items misuse
Misuse of Hospital property
Foul smell from bathroom drain
Foul smells from A/C systems
Generator Failure
Malfunction of Automated Doors
Medical gas leaks
Poor maintenance response
Overflow of Sewage
Disruption of water systems/ services/Flooding
Water leaks
Disruption of AC systems
issue in Chiller
Delay in maintenance work
Major Disruption of power supply
Major Disruption of water systems/ services or Flooding
Steam Drop
Environmental/ Safety
*
Fire
Blocked access to emergency exit doors
Blocked access to firefighting equipment
Blocked corridors and hallways
Defective fire sectoring doors
Exposed electrical wiring
No/poor response from dispatcher
External projects safety violations
Fire Alarm Related Issues
Fire and Safety hazards
Improper emergency exit sign (Missing or defective)
Improper condition of firefighting systems (e.g. Over-due inspection)
Projects safety violations (Internal/External)
Fire alarms not working
Noise pollution
Improper usage of personal protective equipment (PPE)
Emergency call system malfunction
Monitor Alarm Turned Off
Safety precautions not followed
Fire room blocked
Heavy hanged equipment fall to the floor
Lack of ramp for emergency evacuation
Violating Smoking Policy
Improper uses of fire hose reel
Broken medical gas valve box
Electrical cabinet room not locked
High pressure supply of Nitrous oxide
Improper gas storage / not secured
Improper handling of biohazard waste
improper storage of chemicals
No call bell inside the bathroom
No fire alarm pull station
No warning sign upon mapping the floor
Oxygen cylinder regulator not connected properly
Oxygen cylinders not replaced
Sharp edge plate on main access door
Smoke detector removed
Unknown chemical, potentially hazardous
Accommodation related issues
*
The Arrival of candidates to accommodation without Prior Notice form HR/ Recruitment
Delay of Housing Maintenance
Furniture misuse
Lack of Cooking Facilities
Lack of Laundromat Facilities
Lack of Refrigerator Facilities
Housing security
Unauthorized design modification
Unsafe Environment
Information technology related issues
*
Abuse of system authorities
"Accessing systems using someone else’s authorization e.g. someone else’s user id and password"
Disruption of Information Technology services
Information security Issues
Information leakage due to software errors
Spreading of viruses
Poor IT response.
Lack of IT Supplies (e.g. ink, PC, scanner, printers, DSL Modem, phone, pager)
Posting or sharing official or patient information on social networking websites.
"Someone asking to reset passwords not belonging to them"
Security weakness within the system
Inappropriate storage facilities for patient related information
Medical imaging and diagnostic procedure
*
Delay of reporting Images for diagnosis
Failure to comply with reporting of critical finding
No NPO Order
High Creatinine Level
Food services
*
Cold meal delivered
Delayed meal delivery
Foreign object found in food
Lack of information on meal request
Incorrect Storage of food
Late meal modifications
Problems related to ordering, prescription and serving of feed/ foods/fluids
Storage of expired food
Wrong meal request
Diet for Wrong Patient
Wrong Diet
Wrong Quantity
Expired-food item/formula
Food trays not distributed
Food wastage
Inappropriate Formula Labeling
Patient NPO/ Food served
Clinical Nutrition
*
Absence of diet Order by Physicians
Absence/ Delay of diet recommendation by Clinical Dietitian
Incorrect patient diet
Absence/Delay of Nutritional Assessment of Clinical Dietitian
Wrong Frequency by Clinical Dietitian
Diet order not updated
Known allergy
Incorrect order
Unknown allergy
Infection Control related issues
*
Pest Control
Overfilling sharp containers
Protocols for Handling of Body Fluids/Tissues
Device, Product, Medication, Fluid Associated Infections
Hand-hygiene Processes/ Procedures
HazMat
Protocols for Immunocompromised Patients
Medical Waste
Improper Practice of Infection Control Recommendations
Protocols for Infected Patients
Non-Availability of Biohazard Spill Kit
Safe Injection/ Sharps Disposal Processes/ Procedures
Exposure to infected persons/ areas
Intravascular Cannula
Infected Prosthesis/Site
Non-compliance with bundles
Collecting waste bags
Improper biohazard sharps disposal
Improper cleaning
Improper infected & contaminated laundry handling
Improper medical waste collection
Lack of pre- operative cleaning
Contamination Body
Improper Dressing
Lack of follow up on patient LABELLED FOR ISOLATION
Negative pressure not functioning
Poor hand hygiene
Patient not placed in isolation room
Porta cath line infection
Positive result endotoxin from carbon filter
RO2 sample not collected for disinfection
Sharp container not available
Occupational health
*
Manual handling
Accidents caused by external projects
Accidents caused by internal projects
Contact with hazardous substance
Accidental exposure to radiation
Other sharps injury
Electric shock
Injury from facility damages (Falling tiles etc.)
Lifting Equipment or Machinery
Slips, trips and collisions
Injury caused by physical or mental strain
Traffic Accident (Outside the organization performing organizational duty)
Injury caused by workplace violence or assaults
Housekeeping
*
Cleanliness of facilities
Poor housekeeping response
Lack of housekeeping items supplies
Medical/non- medical waste mixing
Misuse of housekeepers
Intravenous
*
Grade 1/ Extravasation
Grade 2/ Extravasation
Grade 3/ Extravasation
Grade 4/ Extravasation
Accidental Dislodgement
Occlusion
Infiltration
Wrong Label/ Instruction
Accidental Removal/ Dislodge
Phlebitis
Remove / Changed without Order
Not Sutured
Wrong Connection
Wrong insertion
Long time to change
Leaking
Pressure ulcer (injury)
*
Stage 1
Stage 2
Stage 3
Stage 4
Deep Tissue Injury
Indeterminable/ Mucous Membranes
Indeterminable/ Under Non- Removal Dressing or Device
Suspected Deep Tissue Injury
Unstageable
Skin lesions/ Integrity
*
Abrasion
BruiseSkin Lesion
Cut Wound
Hematoma
Skin tear
Surgical wound site
Redness
Skin peeling
Cellulitis
Excoriation
Rash
Blister
Wound Dehiscence
Medication
*
Adverse Drug Reaction
Administration, Dispensing, Documentation, Monitoring, Preparation, Prescribing, Transcribing
Adverse Drug Reaction
*
Preventable Adverse Drug Reaction
Non-Preventable Adverse Drug Reaction
Administration, Dispensing, Documentation, Monitoring, Preparation, Prescribing, Transcribing
*
Wrong administration technique
Patient allergic to treatment
Charting error
Communication problem
Compliance error
Contraindication
Medication Delivery Delay
Wrong/unclear dose
Drug-drug interaction
.Drug passed expiry date
Wrong dosage form
Wrong frequency
Wrong/omitted height
High Alert Label Missing
Wrong/omitted patient information leaflet
Medication duplication
Wrong patient
Omitted medicine label
Omitted medicine/ingredient
Omitted/Wrong diagnosis
Wrong method of preparation
Wrong quantity
Adverse drug reaction (when used as intended)
Wrong route
Wrong storage
Unauthorized prescriber
Medication unavailable
Wrong/omitted verbal patient directions
Wrong/omitted weight
Wrong/omitted expiry date
Wrong medicine label
Wrong/unclear strength
Wrong drug/medicine
Wrong/unclear indication
Wrong/unclear rate
Wrong/unclear administration time
Wrong/unclear duration
Communication issues
*
Poor call center response
Communication between staff, teams or departments
Communication with the patient (other than consent issues)
Failure of Emergency-Call system
Failure of paging system
Failure of telephone system
Out On Pass Policy
Transport Schedule/Policy
Delay of response
Difficulty in communicating critical lab results
Inappropriate communication
Inappropriate response to emergency call
Incorrect interpretation
Unprofessional communication
Wrong information communicated
Miscommunication
Acceptance/ eligibility issues
Falls
*
Assisted Falls
1st fall and Assisted fall
1st fall
Out On Pass
Repeated and Assisted fall
Near Fall
Repeated falls
From Bed
From Chair
From Crib
Fall during play
Developmental fall
Baby child dropped
From Exam/ Operating Table
From Isolette
From Lift/Hoist
From Play Equipment
From Stretcher
From Toilet/ Commode
From Radiant Warmer
From Wheelchair
In Shower/Tub
On Stairs
While Ambulating
While Running/ Playing
Unknown/Found on Floor
Radiation treatment (Ionizing radiation Non- Ionizing (US, UV, MRI, Laser, other)
*
Eye or face splash
Radiopharmaceuticals decay
Radiopharmaceuticals Expiry
Radiation unnecessary exposure
Radiopharmaceuticals mislabeling
Radiopharmaceuticals leakage
Radiopharmaceuticals wrong location
Radiopharmaceuticals mishandling
Radiopharmaceuticals missing
Radiation overdose
Radiopharmaceuticals shortage
Radiopharmaceuticals spill
Radiation under- dose
Cluttered area
Poisoning
Labor and Delivery related issues
*
NICU Admissions for Baby above 36wks
Placental abruption
Anesthetic problem connected with labor or delivery
APGAR score less than 7 (at 5 minutes)
Born before arrival
Breech presentation
Birth – Related Trauma
Cord prolapse
Undiagnosed cephalo-pelvic disproportion
Elective Caesarean Section
Emergency Caesarean Section
Difficult delivery
Shoulder dystocia
Fetal distress with Poor Outcome
Labor assisted by forceps
Unplanned home birth
Delivery using more than one instrument
Intrapartum hemorrhage
IUGR or placental insufficiency
Prolonged first or second stage of labor
Injury or poor outcome for the mother
Labor or delivery – other
Delivery with PH < 7
Post-partum hemorrhage > 1,000ml
Pre-eclampsia
Placenta Previa
Ruptured uterus
Supply Chain issues (logistics)
*
Non availability of medical items in store
Non-Availability of Non-Stock Items
Non availability of furniture items
Non authorized property movement
Overstock of medical items in wards
Unregistered medical device
Damaged Items When Delivered
Delayed medical items delivery response
Lack of stationary items supplies
Medication Out of stock
Medical items alerts/recalls
Laundry services
*
Dirty linen not collected
Lack of laundry services supplies
Poor laundry services response
Sentinel Events
*
Unexpected death
Unexpected loss of limb or function
Wrong patient, wrong procedure or wrong site
Retained instrument or sponge
Serious medication error leading to death or major morbidity
Suicide of a patient in an inpatient unit
Maternal death
Hemolytic blood transfusion reaction
Air Embolism
Death of a full term infant
Transmission of a chronic, fatal diseases or illness as a result of infusing blood or blood products or transplanting contaminated organs or tissue
Deviation from standard of care (e.g. Policy, procedure, protocol, delay in management) that lead to death or serious harm.
Child/ Infant abduction
Infant discharged to a wrong family
Rape
Workplace violence such as assault; or homicide (willful killing) of a patient, any employee, visitor or sub-contractors while on hospital property.
Fire: Major destruction or loss of function to the surrounding environment (natural or facility), events that result in death
Suicide of staff, visitors, watchers anywhere on property
Critical equipment breakdown or failure when in use
Unintended collapse of any building or structure under construction or alteration
Collapse or overturning of any load bearing part of any lift or lifting equipment when in use
ID/Documentation/ Consent
*
ID
Consent
DNR
Documentation
ID
*
Absent
Illegible
Wrong MRN
Wrong Name
Wrong Patient
Consent
*
Abbreviation Used
None
Unsigned
Wrong Procedure Listed
Wrong Patient
Wrong Side/Site Listed
Wrong Signature
DNR
*
Absent
Incomplete
Unclear
Unsigned
Documentation
*
Altered
Illegible
Inadequate
Inappropriate
Incorrect
Misfiling
Legal Guardian Signature Missing
Unsigned Notes
Unsigned Telephone Order
Wrong Addressograph
Description of the event
*
Description of incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible)
*
Immediate Action / Treatment Following the Incident:
*
Recommendations to prevent the occurrence of similar incidents in the future:
*
Incident Outcome:
Status of affected person after incident occurrence:
*
Stable
Not stable
Level of Harm after incident occurrence : For medication related Incidents
*
Circumstances or events that have the capacity to cause error.
An error occurred but the error did not reach the patient.
An error occurred that reached the patient but did not cause patient harm.
An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm.
An error occurred that may have contributed to, or resulted in temporary harm (minor injury) to the individual and required intervention
An error occurred that may have contributed to, or resulted in temporary harm (minor injury) to the individual and required intervention and initial or prolonged hospitalization.
An error occurred that may have contributed to, or resulted in individual harm (serious injury - prolonged the stay or extensive follow up).
An error occurred that resulted in life-threatening injury or multiple serious injuries causing hospitalization and required intervention necessary to sustain life.
An error occurred that may have contributed to or resulted in the patient’s death.
Level of Other Types of Incidents:
*
None: (Incident occurred with no harm to the patient or person involved).
Minor: (No change in vital signs. Non-invasive diagnostic test required. Increased observation or monitoring required)
Moderate: Vital signs changes. Decreased level of consciousness. Additional medication/treatment required. Invasive diagnostic procedure required
Major: Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.
Catastrophic: Incident resulting in death.
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