Critical Incident Form

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Critical Incident Form

Department of Anaesthesia & Intensive Care
Eric Williams Medical Sciences Complex

Please fill out all details as best as possible

* Indicates required field

Date *

Time *

AM/PM *

Location *

If other, please state *

Gender *

Male Female

Age *

ASA (Anaesthesia Cases) *

Urgency (Anaesthesia Cases) *

Describe What Happened *

Give a factual description of what happened. Do not include speculation on causative factors.

Nature of Incident *

Surgical event/error Device or product failure Patient protection event Staff protection event (physical/infectious) Environmental event Care management event Criminal event Anaesthesia related event Medication error Self-harm/intentional injury to patient Violence towards staff/self-harm Infection control issues/contamination Lack of proper procedure/technique Physical assault/abduction

Anaesthesia/ICU Staff present *

Consultant Registrar House Officer None

Other Specialty Doctors Present *

Consultant Registrar House Officer None

State other specialties involved *

Other Staff Present *

Nurse Escort ADA SDA ENA Janitorial Staff Security Clerical Staff Administration Technician None

Interventions performed *

Interventions performed DURING THE EVENT and IMMEDIATELY AFTER

Contributing Factors *

Lack of knowledge Use of unfamiliar procedure or device Staffing issues Lack of appropriate equipment Breach of policy/procedure Ineffective communication Interference Inappropriate labelling Lack of consumables Lack of drugs Delay to obtain drugs/equipment Poor documentation Unsuitable storage Misuse of abbreviations/short-hand Other

Fill out if Other *

Effect on patient *

Effect on Staff *

Was event preventable? *

How do you think this might be prevented from happening again? *

Submit

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Home
- Feedback
Anaesthesia & AICU Projects
PICU Projects
- PICU Crash Sheet
- Bed Booking Form: PICU
Other Projects
- CMJ-test
Brewing Creations
- Mead-Semisweet
PDFs
Private Documents