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Name: __________________________________________ Date: _____________ Score: _____________
Procedure 42–1 Steps
Start Time: End Time: Total Time:
Steps
Possible
Points
First
Attempt
Second
Attempt
Third
Attempt
1. Report the incident immediately to a supervisor for
documentation.
15
2. Assemble equipment. 15
3. Fill in the demographic information about the patient. 15
4. Fill in location of the event. 15
5. Complete the section regarding information about the
patient factors prior to the event.
15
6. Fill in the categories of event section. 15
7. In the space provided, give a written description of the
event.
15
8. Add any additional persons involved. 15
9. Complete the review section. 15
10. Complete the corrective action section. 15
11. Complete the procedures followed section. 15
12. Complete the family/patient attitude after the event
section.
15
13. Add any additional information that may be warranted
and obtain signatures, titles, and dates.
15
14. Forward form to the risk management department
following the office protocol so proper action can occur.
15
Points Awarded / Points Possible _____/
210
