Patient Injuries at Cardiology Medical Group

In the event that a patient is injured at Cardiology Medical Group, steps must be taken to ensure the safety of the patient and properly report the incident.

1. When the injury occurs, take steps to properly protect and provide the ability to care for the patient.

2. Immediately notify a physician of the incident.

3. The physician evaluates and provides immediate care to stabilize the patient.

4. If the patient needs to be transported to a hospital, follow the procedure given in Transfer of Patient to Ambulance.

5. Complete a Physician Office Adverse Incident Report with the following information:

• Office information

• Patient information

• Incident information

• Analysis and corrective action

• Physician’s signature

You can see a sample of this form starting on the next page.

		STATE OF STATE Name, Governor PHYSICIAN OFFICE ADVERSE INCIDENT REPORT SUBMIT FORM TO: Department of Health, Consumer Services Unit Medical Way City, ST 11111
I. OFFICE INFORMATION __________________________________________ Name of Office				__________________________________________ Street Address
______________________ _________ _________ City Zip Code County				__________________________________________ Telephone
__________________________________________ Name of Physician or Licensee Reporting				__________________________________________ License Number & Office Registration Number, if applicable
__________________________________________ Patient's Address for Physician or Licensee Reporting
II. PATIENT INFORMATION __________________________________________ Patient Name				________ ___________ q q Age Gender Medicaid Medicare
__________________________________________ Patient Address				__________________________________________ Date of Office Visit
__________________________________________ Patient Identification Number				__________________________________________ Purpose of Office Visit
__________________________________________ Diagnosis				__________________________________________ ICD-9 Code for Description of Incident
				__________________________________________ Level of Surgery (II) or (III)
II. INCIDENT INFORMATION __________________________________________ Incident Date and Time				Location of Incident q Operating Room q Recovery Room q Other _____________________
If the incident involved a death, was the medical examiner notified? q Yes q No Was an autopsy performed? q Yes q No
A) Describe circumstances of the incident (narrative) (use additional sheets as necessary for complete response) _____________________________________________________________________________________
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B) ICD-9-CM Codes
____________________________ Surgical, diagnostic, or treatment procedure being performed at time of incident (ICD-9 Codes 01-99.9)	________________________ Accident, event, circumstances, or specific agent that caused the injury or event. (ICD-9 E-Codes)				________________________ Resulting injury (ICD-9 Codes 800-999.9)
C) List any equipment used if directly involved in the incident (use additional sheets as necessary for complete response) _____________________________________________________________________________________
D) Outcome of Incident (Please check)
q Death q Brain damage q Spinal damage q Surgical procedure performed on the wrong patient. q A procedure to remove unplanned foreign objects remaining from surgical procedure. q Any condition that required the transfer of the patient to a hospital. Outcome of transfer – e.g., death, brain damage, observation only Name of facility to which patient was transferred: ____________________________________________			q Surgical procedure performed on the wrong site q Wrong surgical procedure performed q Surgical repair of injuries or damage from a planned surgical procedure. ** if it resulted in: q Death q Brain damage q Spinal damage q Permanent disfigurement not to include the incision scar q Fracture or dislocation of bones or joints q Limitation of neurological, physical, or sensory function q Any condition that required the transfer of the patient to a hospital
E) List all persons, including license numbers if licensed, locating information, and the capacity in which they were involved in this incident. This would include anesthesiologist, support staff and other health care providers. _____________________________________________________________________________________
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F) List witnesses, including license numbers if licensed, and locating information if not listed above. _____________________________________________________________________________________
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IV. ANALYSIS AND CORRECTIVE ACTION A) Analysis (apparent cause) of this incident (Use additional sheets as necessary for complete response) _____________________________________________________________________________________
B) Describe corrective or proactive action(s) taken (Use additional sheets as necessary for complete response) _____________________________________________________________________________________
_____________________________________________________________________________________
V. _________________________________________________ _________________ SIGNATURE OF PHYSICIAN/LICENSEE SUBMITTING REPORT LICENSE NUMBER _________________________ _________________________ DATE REPORT COMPLETED TIME REPORT COMPLETED