Investigation Outline for a Reportable Incident (NHSF)

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

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

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