Investigation Outline for a Reportable Incident (NHSF)

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, which includes a copy of the patient’s complete clinical report.

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.

This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act.

This report is prepared for the Reportable Incident Review Committee (RIRC). Information within this form is privileged and confidential under Section 9 of the Alberta Evidence Act.


Information & documentation 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
  • Name of person who performed the procedure, and whether they are a Medical Doctor, Dentist, Podiatrist or Oral and Maxillofacial Surgeon
  • The operation proposed and performed
  • Details about the person completing the Incident Report form
  • Patient information, including:
    • If they are a contract patient
    • The patient’s initials
    • Gender
    • Birth date
    • 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 info
    • Emergency contact/access info
  • Date and time patient was discharged from facility

2. Incident Evaluation

We will need specific documentation to review the incident. When completing this incident report form, please upload the following as one file

Evaluation of the Incident:

  1. Description and evaluation of the event by the individual who performed the surgical procedure(s), including:
    • Name and professional designation
  2. Description and evaluation of the event by the individual who performed the sedation/anesthetic procedure(s), including:
    • Name and professional designation
  3. Description and evaluation of the event by at least one peri-operative staff member present during the procedure(s), including:
    • Name and professional designation
  4. Medical Director narrative review of incident, follow-up and actions taken to prevent a reoccurrence of the event, including:
    • Name and professional designation

3. Patient Documentation

Patient Documentation

The patient chart ordered, legible and complete in the following order.

Note: Illegible chart documentation must be accompanied by a transcript of the applicable information.

  1. Pre-operative information
    • Surgical consultation and assessment
      • Completed history and physical
      • Netcare/pharmacy-generated list of medications
      • Applicable diagnostics
    • Anesthetic assessment
    • Patient intake questionnaire
    • Surgical and anesthetic consent, signed and witnessed
    • Pre-operative orders
  2. Intraoperative
    • Surgical safety checklist
    • Surgical record
    • Anesthetic record
    • Progress notes (if applicable)
  3. Recovery
    • Recovery care record
    • Recovery orders
    • Progress notes (if applicable)
  4. Incident
    • Progress notes or standardized incident record
    • If EMS transfer, record of patient handover
    • Doctor (surgeon or anesthesiologist) documentation regarding continuity of care communication with urgent care/emergency department and/or hospital on call physician
  5. Operative report
  6. Post Incident follow up
    • Hospital discharge summary (if possible) or
    • Description of patient follow-up post-incident to indicate if:
      • the patient’s complications are resolved or if they continue
      • any further investigation or treatments will occur
      • the patient will need to be referred for continuity of care
        • Written Discharge Instruction provided to the patient
        • Continuity of care framework for doctor’s (performing the surgical procedure) NHSF patient post discharge

You will not be able to save your progress while filling out this form. Before you begin, please ensure you have all required information & documentation as outlined above.