F-30
Critical Incident / Near Miss Report
دليل السياسات والإجراءات في التخدير — Section M
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F-30 Critical Incident / Near Miss Report (Anesthesia)

ANESTHESIA DEPARTMENT • CONFIDENTIAL • CBAHI/JCI COMPLIANT
This is a confidential patient safety report for quality improvement purposes only - NOT part of medical record
Patient Name: MRN: DOB: Age/Sex: Weight: ASA Class:
Procedure/Surgery: Location: OR ICU ER NORA Other
Date of Incident: Time: Anesthesiologist: Reporting Person: Role:
⚠️ 1. INCIDENT CLASSIFICATION
Incident Type
Critical Incident (actual harm)
Near Miss (harm prevented)
Adverse Event (unintended harm)
Sentinel Event (death/serious harm)
Severity Level (if harm occurred)
Level 0: No harm
Level 1: Minor temporary harm
Level 2: Moderate temporary harm
Level 3: Severe permanent harm
Level 4: Death
Immediate Outcome
No patient harm
Patient harm - fully recovered
Patient harm - ongoing treatment
ICU admission required
Death Other: ______
Phase of Care
Pre-operative assessment
Pre-induction preparation
Induction
Maintenance
Emergence/Extubation
Recovery/PACU
Post-operative period
Critical care
Other:
Time Since Anesthesia Start
hours minutes
Patient Status at Time of Incident
Awake
Sedated
Under general anesthesia
Under regional anesthesia
Recovering from anesthesia
Other:
📋 2. INCIDENT CATEGORY (Select all applicable)
Equipment/Technical
Equip failure/malfunction
Equipment misuse
Equipment unavailable
Monitoring failure
Ventilator malfunction
Infusion pump error
Anesthesia machine
Airway equip issue
Other: _______
Medication/Drug
Wrong drug
Wrong dose
Wrong route
Allergy/reaction
Interaction
Labeling error
Prep error
Storage issue
Other: _______
Airway/Respiratory
Difficult/failed intubation
Accidental extubation
Aspiration
Bronchospasm
Laryngospasm
Hypoxemia
Hypoventilation
Pneumothorax
CICV / Other: _______
Cardiovascular
Hypotension
Hypertension
Bradycardia
Tachycardia
Arrhythmia
Cardiac arrest
Myocardial infarction
Hemorrhage
Anaphylaxis / Other: _______
Neurological
Awareness
Seizure
Stroke/CVA
Nerve injury
Spinal/epidural issue
LA toxicity
Brain injury
Delayed emergence
Other: _______
Communication/Process
Miscommunication
Documentation error
Patient ID error
Wrong site/side
Consent issue
Delay in care
Team coord failure
Handover issue
Other: _______
📝 3. DETAILED INCIDENT DESCRIPTION
What happened? (Describe in detail)
Where? Location: Room/Bay:
Who was involved?
🔍 4. CONTRIBUTING FACTORS
Human & Environmental
Fatigue/sleep deprivation
Distraction/interruption
Workload/time pressure
Lack of knowledge/training
Communication failure
Supervision inadequate
Poor lighting/Noise
Space constraints
System & Patient
Inadequate staffing
Inadequate equipment
Protocol unclear/not followed
Lack of standardization
Complex medical history
Emergency procedure
Difficult anatomy
Patient cooperation
✅ 5. IMMEDIATE ACTIONS TAKEN
What immediate actions were taken?
Emergency assistance called? No Yes (Who: Time: )
Resources used: Airway Cart MH Cart Emerg Drugs Defib Advanced Airway Extra Staff
Outcome: Stable-continued Stable-aborted ICU Higher Care Death
🎯 6. ROOT CAUSE ANALYSIS
Why did this occur? (Root Causes)
Preventable? Yes No Uncertain
If yes, how?
Contributing organizational factors:
Policy/protocol gaps
Training/education gaps
Equipment/resource gaps
Communication gaps
Supervision gaps
Culture/safety climate
Similar incidents past? No Yes Unk
Describe:
💡 7. RECOMMENDATIONS & ACTION PLAN
Action Recommended Responsibility Priority Timeline Status
System-Level Improvements: Protocol Equipment Training Communication Monitoring Checklist
Specific recommendations:
📞 8. NOTIFICATION & FOLLOW-UP
Notifications Made
Patient/Family - Time:
Dept Head - Time:
Risk Mgmt - Time:
Quality & Safety - Time:
Med Director - Time:
Admin - Time:
External Auth: Time:
Documentation & Follow-Up
Medical record doc Event report filed
Equip quarantined Photos collected
Witness statements
Required:
Pt follow-up (Date:)
M&M Conf (Date:)
Dept Mtg (Date:)
Staff counseling
👤 9. REPORTER DETAILS
Name: Role:
Contact: Date:
Involvement: Primary Assisting Witness Informed
Signature:
✍️ 10. DEPT HEAD REVIEW
Class: Critical Near Miss Adverse Sentinel
Investigate? No Yes (Type:)
Reviewed By:
Sig: Date:
⚠️ CONFIDENTIAL PATIENT SAFETY REPORT - This document is protected under patient safety statutes. It is NOT discoverable or admissible in legal proceedings. This report is for internal quality improvement only and should NOT be placed in the patient's medical record.
Form F-30 | Critical Incident / Near Miss Report | Version 1.0 | Page 2 of 2 | CONFIDENTIAL - NOT PART OF MEDICAL RECORD
COP.3 (Quality & Patient Safety) • COP.7 (High-Risk Processes) • GLD.7 (Quality Management) • IPSG.1 • CBAHI/JCI Standards