Patients & Visitors
Occurrence Report
Date Occurred:
* Required
Individuals Involved:
* Required
Department/Location:
* Required
Is this a good catch?
Yes
No
Did the occurrence require any outside entity?
Yes
No
* Required
Which entity?
* Required
Injury:
Yes
No
* Required
Name of injured person:
* Required
Was a patient involved?
Yes
No
* Required
Is this a medication error?
Yes
No
* Required
Medication Error Category
- Select -
Category A
Category B
Category C
Category D
Category E
Category F
Category G
Category H
Category I
Visit #
* Required
Was a physician notified?
Yes
No
* Required
Physician Name:
* Required
Date and Time Physician was Notified:
* Required
Witness(es) Name(s) and Contact Information:
* Required
Individual completing form:
* Required
Supervisor Notified:
* Required
Date and Time Supervisor was Notified:
* Required
Description of Occurrence:
*Keep the description brief and only include the facts of the occurrence
* Required
Submit Occurrence Report