Patient Safety Incident Report
Anything that harmed a patient, or could have. Any type. Anonymous if you wish. Ten minutes
What it is
A universal incident and near-miss report based on the WHO minimal information model: type, what happened, patient outcome, contributing factors, immediate actions, reporter suggestions — anonymous by default, with the manager's review section.
Where to use it
Every ward and department; paper box and online; reviewed within 72 hours by the safety lead. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy. Evidence for: Governance chapter — incident reporting and learning; Sentinel Event Policy.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Incident Severity and Response Matrix
Root Cause Analysis — Worksheet
Just Culture — Decision Guide for Managers
Safety Learning Bulletin — Monthly, One Page
Print to share.
