Physician Office Adverse Incident Report - Florida Department Of Health (Page 2 of 3) in pdf

_________________________________________________________________________________________________________________

B) ICD-9-CM Codes

______________________________

Surgical, diagnostic, or treatment

Accident, event, circumstances, or

Resulting injury

procedure being performed at time of

specific agent that caused the injury

(ICD-9 Codes 800-999.9)

incident

(ICD-9 Codes 01-99.9)

or event. (ICD-9 E-Codes)

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

)



Death



Surgical procedure performed on the wrong site **



Brain Damage



Wrong surgical procedure performed **



Spinal Damage

Surgical repair of injuries or damage from a planned

surgical procedure.



Surgical procedure performed on the wrong patient.

** if it resulted in:



A procedure to remove unplanned foreign objects



Death



remaining from surgical procedure.

Brain Damage



Spinal Damage



Any condition that required the transfer of the

Permanent disfigurement not to include the

patient to a hospital.

incision scar



Fracture or dislocation of bones or joints

Outcome of transfer – e.g., death, brain damage,



Limitation of neurological, physical, or sensory

observation only ___________________________

function.



Name of facility to which patient was transferred:

Any condition that required the transfer of the

patient to a hospital.

________________________________________

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.

_____________________________________________________________________

List witnesses, including license numbers if licensed, and locating information if not listed above

_____________________________________________________________________

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)

_____________________________________________________________________

DH-MQA1030-12/06

Page 2 of 3

Physician Office Adverse Incident Report - Florida Department Of Health Page 2

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