Da Form 4106 - Incident Report Page 2

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1. PURPOSE. To provide an effective method of documenting events which may have quality assurance/risk management implications involving
patients, visitors, or others. The reported data are used to monitor, evaluate, and improve functional processes, the environment of care, as well as the
quality and safety of patient care and services. Based on the nature of the incident, other documentation (e.g., Patient Safety, Risk Management, etc.)
may be required IAW local policy.
2. RESPONSIBILITY. The staff member who discovers the event or incident will initiate this document. All incidents should be recorded as soon
after discovery as possible.
3. DIRECTIONS FOR COMPLETION OF FORM.
a. Block 1-16. Fill in all numbered blocks. If "Not Applicable" or "None", so state. If "Other" is marked for any response, please explain in the blank
space provided, or in Block 11, Description of Incident.
b. Block 5. For those incidents involving harm, or the potential for harm, to a patient (inpatient or outpatient), refer to MTF Patient Safety
guidance for additional documentation requirements.
c. Block 6. A patient may be involved in an incident that is
not classified as a Patient Safety event, i.e., personal harm, or the risk of harm,
was not present. Examples include: loss of valuables, a verbal altercation with another patient, etc.
d. Block 7.
(1) For an adverse drug reaction, also complete FDA Form 1839, Adverse Reaction Report (Drugs and Biologics).
(2) For a blood products reaction, also complete the bottom portion of SF 518, Medical Record - Blood or Blood Component
Transfusion and any other local documentation IAW MTF policy.
(3) For patients who depart AMA/Left without Being Seen, also complete DA Form 5009, Release Against Medical Advice.
(4) For medical equipment related incidents, contact Logistics Division for other required action IAW AR 40-61.
e. Block 8. Indicate the initial effect or injury (physical or psychological) sustained by those involved in the incident being reported.
Individuals who are injured as a result of an incident or adverse event should be referred immediately for medical attention.
The facility Risk Manager will be notified of any incident that results in harm to the individual(s) involved.
f. Block 9.
List any witnesses to the event that may be asked to provide additional verbal or written information.
g. Block 10.
Note the departments involved with this incident to ensure that corrective action, if appropriate, can be taken.
h. Block 11.
Provide a brief but concise explanation of what occurred. Avoid speculation related to the cause of the incident.
4. ROUTING OF FORM. This document should be forwarded through appropriate local channels. At a minimum, it should be staffed within 24 hours
of incident identification through the Departments/Services concerned. This form will be submitted to the MTF Patient Safety Manager, Risk Manager,
or other responsible individual IAW local policy, NLT 48 hours after the event.
5. DEFINITION OF TERMS.
a. Actual Event/Incident - A situation that did occur either with or without harm or injury to the individual(s) involved.
b. Harm - Personal injury or damage of a physical or a psychological nature as a result of an incident.
c. Near Miss/Close Call - An event or situation that could have resulted in harm or injury to the individual(s) involved but did not, either by chance or
through timely intervention. The event was identified and resolved before reaching the individual(s) involved.
6. ADDITIONAL COMMENTS/DATA.
Page 2 of 2
DA FORM 4106, FEB 2004
APD LC v1.01ES

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