CST Investigation Outline for a Reportable Incident form

Before starting this form, make sure you have the following documents:

Copy of the patient’s clinical record
Narrative summary from the physician most involved with the case describing the incident, action taken, possible risk factors and outcome

Mandatory Reporting & Documentation
Within one (1) working day after discovering a reportable incident, the Facility Medical Director must notify CPSA at 780-423-4764 or 1-800-561-3899.

Within two (2) weeks of the incident the facility must submit this form, which includes uploading a copy of the patient’s complete clinical record and a narrative summary from the physician most involved with the case.

The Deputy Registrar may review the circumstances with the Medical Director and may consult with other practitioners to determine the risk of harm to patients. If necessary, the Deputy Registrar may suspend the accreditation of any facility on a suspicion of continuing risk.
Facilty Name:*
Facilty Number:*
Facility Contact Email:*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email
Name of Medical Director:*
First Last
Type of incident:
- Deaths within the facility
- Cases requiring cardiopulmonary resuscitation within the facility
General Information
Date of incident (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023). :
MM slash DD slash YYYY
Test performed by:
First Last
The above individual is a:
- Medical Doctor
- Physician
Test Proposed:
Test Performed:
Person completing this Incident Report:
(Must be a regulated health professional)
First Name Last Name Title/position Phone
Patient Information
Patient Identification Number:
Gender:
- Male
- Female
- X
Age:
Description of the event
Describe what happened (brief details of events):
Describe where it happened (e.g., exact location in the facility):
What was the outcome of the transfer (e.g. diagnosis, length of stay, sequelae, etc.)?
History of the event
Describe contributing factors to the incident for each of the following, as applicable:
Patient (coexisting disease conditions, language barriers):
Personnel (e.g. number, training, experience, performance):
Equipment (list any equipment that may have played a role in the incident):
Environment (e.g. noisy, crowded):
Facility response to the event
If this incident had progressed without corrective action, what might the outcome have been for the patient?
What prevented this incident from becoming more serious?
What steps have been taken to prevent future occurrences? (e.g. change to policy or procedures)
Additional documents
Please provide a copy of the patient's clinical record:*
Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.
Please provide a narrative summary from the physician most involved with the case describing the incident, action taken, possible risk factors and outcome:*
Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.
Signature
Medical Director - Checking this box will act as your signature:*
I have reviewed the content of this report
Name:*
First Last
Email:*
Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023):*
MM slash DD slash YYYY
This report is prepared for the Medical Facility Accreditation Committee (MFAC) and is privileged and confidential under Section 9 of the Alberta Evidence Act.
Comments
This field is for validation purposes and should be left unchanged.

Before starting this form, make sure you have the following documents:

Mandatory Reporting & Documentation

General Information

Patient Information

Description of the event

History of the event

Facility response to the event

Additional documents

Signature

CPSA's 2023 annual report now available

First Name	Last Name	Title/position	Phone