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 record.

    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.
  • Date Format: DD dash MM dash YYYY
  • General Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • First NameLast NameTitle/positionPhone 
    (Must be a regulated health professional)
    (For Regional Health Authority contracted facilities only)
  • Patient Information

  • BPPulseO2 SaturationTemperature
  • CBCHgBWBCINRPlateletsElectrolytes
  • Drop files here or
  • ECGChest x-rayCTMRI
  • Unremarkable or RemarkableAdditional comments, if applicable 
  • Unremarkable or RemarkableAdditional comments, if applicable 
  • Unremarkable or RemarkableAdditional comments, if applicable
  • Operative details - Intraoperative

  • Operative details - Post Anesthesia Recovery

  • Number of daysUnremarkable or RemarkableOr additional comments if applicable 
  • (e.g. blood loss, decrease oxygen saturation, increased BP, wheezing, pain, etc.)
  • Discharge:
  • Operative details - Summary of Complication

  • (Describe contributing factors to the incident, e.g. co-existing comorbidities, language barrier, clinical personnel issues, equipment failure, environmental issues, diagnostic testing, blood work, pathology anomalies, etc.)
  • Operative details - Management of Complication

  • Date Format: DD dash MM dash YYYY
  • :
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • (i.e., obtained either directly from the patient, family members, surgeon, anesthesiologist, attending ER physician, any other specialist)
  • Operative details - Documentation

  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Drop files here or
    Accepted file types: jpeg, png, jpg, tiff, pdf.
  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Drop files here or
    Accepted file types: jpeg, png, jpg, tiff, pdf.
  • Signature

  • This is the email address we will send a submission confirmation notification to.
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • 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.

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