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Event details by discoverer/reporter

REPORTING SPECIALTY

Occurrence Date and time

Discovery Date and time

Event area Select the area Dedicated patient care areaPublic complex areasNon-patient work areaExternal perimeter of the complex

Choose the exact location of the event such as the clinic or room number or write it manually.

The exact location must be written, such as the clinic or room number, etc.

Departments Involved Select the relevant department doctorsNursingThe laboratoryRaysTherapeutic nutritionnatural therapyHigher ManagementHRAccountingcustomers serviceEmploymentinformation technologypharmacyMarketingqualityLegal Affairs

Are there any affected people? Select yes or no YESNO

Select the affected people Affected people one patient affectedtwo patient affectedone staff affectedtwo staff affectedone visitor affected

Visitor's name Patient file number Employee ID/Residence Number

Visitor's mobile number Patient file number Employee ID/Residence Number

Incident Type Please check the relevant fields

Type of incident Basic classification Select the primary classification AdministrativeCommunicationFacility ManagementSecurity VarianceSafetyMedical & Clinical CareTreatment/Test/Procedure

Incident Type Secondary Classification

Incident Type Analytical Classification

Add a new analysis type

Event Description by Reporter/Discoverer

Occurrence Description: (If more space is needed, please attach your description)

Immediate action taken by the discoverer

Select action None NeededRemoved obstacleProvided First AidProvided assistance to manage the incident

Request help from Immediate SupervisorHousekeepingMaintenanceSecurityInfection ControlPatient Safety OfficerEnvironmental Safety OfficerOther

Select other help

Immediate action taken by discoverer/others: