Critical Incident Reporting Form- Simple Forms service

The following form is to be completed and submitted in compliance with SLTC Critical Incident Reporting Policy ( https://novascotia.ca/dhw/ccs/policies/Critical_Incident_Reporting_Policy.pdf ) within one business day of a critical incident. The completed form will go directly to the Department of Seniors and Long-Term Care (SLTC)

Please do not include any personal health information (including personal information) in any of the below form fields. Doing so will constitute a privacy breach.

Today's Date (mm/dd/yyyy)

Contact Information of Submitting Person:

First Name of Person Submitting Report:

Last Name of Person Submitting Report:

Date incident occurred (mm/dd/yyyy):

Time incident occurred:

Location of incident:

Nature of Incident: (please check):

Please select what best describes the nature of the incident

Unanticipated death/serious health impairment to client/visitor/health care personnel directly associated with care/services

Unanticipated disruption to health care services for greater than 24 hours

Events involving multiple clients and/or requiring retroactive notification of event/exposure to risk

Privacy breach which may impact public trust

Conditions perceived as public health hazard/disaster management events

Criminal activity (such as abduction, sexual assault, major theft, embezzlement)

Events with potential to undermine public confidence in the health care system

Other – serious event regarding which the service provider believes DSLTC should be notified

It is the responsibility of the service provider to report to any other applicable agencies such as the Medical Examiner, Public Health, Police, Public Trustee etc. as per your established procedures.

Safety Incidents

Service Providers are expected to have safe work practices, policies and procedures in place to prevent and respond to critical incidents. Reporting a critical incident to the department is an important part of managing an incident and does not eliminate a service provider’s responsibility to address and document incidents as well as engage all appropriate parties and resources.

Description of Incident:

You have 5000 characters remaining.

Did the client(s), visitor(s) or staff member(s) sustain an injury?

YES

UNKNOWN

If YES, please describe the injury:

You have 5000 characters remaining.

Is the client’s family or substitute-decision maker aware?

YES

Has this incident been reported through Protection for Persons in Care?

YES

Not Applicable

Has this incident been reported to NSH?

YES

Not Applicable

Privacy Statement

The information provided on this form is collected, used, and disclosed in accordance with the Critical Incident Reporting Policy, Personal Health Information Act and the Freedom of Information and Protection of Privacy Act. It will not be collected, used or disclosed, for any other purpose except as authorized by law.

Critical Incident Reporting Form

Reporting a Critical Incident

Contact Information of Submitting Person:

Nature of Incident: (please check):

Safety Incidents

Privacy Statement