© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Name: __________________________________________ Date: _____________ Score: _____________
Competency Checklist
Procedure 42–1: Complete an Incident Exposure Report
Related to an Error in
Patient Care
ABHES Curriculum
MA.A.1.4.e Perform risk management procedures
MA.A.1.4.f Comply with federal, state, and local health laws and regulations as they relate to health care settings
CAAHEP Core Curriculum
X.P.7 Complete an incident report related to an error in patient care
Task: To provide documentation required by the risk management department in the event an error
occurs in regard to patient care.
Supplies & Conditions: Unusual Occurrence Form (UOR) form, pen
Standards: A maximum of three attempts may be used to complete the task. The time limit for each attempt
is 15 minutes, with a minimum score of 70 percent. Scoring: Determine student’s score by
dividing points awarded by total points possible and multiplying results by 100.
Forms: Procedure Form 42–1 (UOR form). Procedure forms can be downloaded from the Student
Companion website.
EVALUATION
Evaluator Signature: Date:
Evaluator Comments:
565
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© 2017 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
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
566