Mandatory reporting & documentation
Within one (1) working day after discovering a reportable incident, the Facility Medical Director must notify CPSA at 780-969-5002.
Within two (2) weeks of the incident, the facility must submit this form.
This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act.
Information required to complete this form
Please expand each of the accordions below for details about what you need to complete this form.
1. General Information
To complete this form, you will need to provide us with:
- Facility name and number
- Medical Director name
- Date CPSA was notified of the incident
- Type of incident
- Date of procedure
- Date of incident
2. Procedure Information
- Name of person who performed the procedure, and whether they are a Medical Doctor, Dentist, Podiatrist or Oral and Maxillofacial Surgeon
- The procedure proposed and performed
- If the service was a Health/AHS contracted service
- Patient information, including:
- The patient’s initials
- Gender
- Age of patient
- ASA Classification
- BMI
- Any relevant contributing pre-operative history
- Any relevant medical/surgical/anesthesia consultation information
- Any medications routinely taken
- Any medications discontinued preoperatively
- Any medications given preoperatively
- Operative details, including:
- Anesthetic type
- Length of procedure
- Surgical safety checklist
- Whether information was provided to the patient, including:
- Verbal post-operative instructions
- Written post-operative instructions
- Facility contact information
- Emergency contact/access information
- Time patient was discharged from facility
3. Incident Evaluation
- Details about facility staff member completing the Incident Report form
- Medical Director evaluation of incident
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Save and continue: Now you can choose to “save and continue” as you fill out this form. Please be advised that the form contents will only be saved for 30 days when using this feature. |
