Note: An agency incident report must also be completed.
NAME OF STUDENT: ________________________________ DATE: ____________________
LOCATION OF INCIDENT: ____________________________________________
1. Describe in detail what occurred. Give specific times wherever possible.
2. What action was taken by you or others after this event occurred and who was notified. Give specific times wherever possible.
3. What negative effect (if any) did this occurrence have on the patient? What assessment findings validate your conclusion?
4. What suggestions do you have to either prevent this from occurring again or for alternative ways to handle a similar situation?
Student Signature__________________________________ Date_____________________
5. What needs to be done to correct this error?
6. Remedial action carried through. Cite dates when remediation will be complete and any further action taken.
Nursing & Health Sciences Chair
cc: Program Director/Coordinator
Assistant to the Chair (Assessment Director/Coordinator)