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CQI Form 20150401

This document is a form for reporting continuous quality improvement (CQI) and contains sections for reporting patient information, details of an event, immediate corrections/actions taken, analysis of contributing factors, and required preventative actions. The form is to be completed within 24-48 hours of an event and focuses on objective information to ensure non-punitive quality improvement. Events are categorized from A to I based on level of harm and higher categories require root cause analysis. All reports are maintained confidentially.

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TOUSHIFAHEMED
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523 views2 pages

CQI Form 20150401

This document is a form for reporting continuous quality improvement (CQI) and contains sections for reporting patient information, details of an event, immediate corrections/actions taken, analysis of contributing factors, and required preventative actions. The form is to be completed within 24-48 hours of an event and focuses on objective information to ensure non-punitive quality improvement. Events are categorized from A to I based on level of harm and higher categories require root cause analysis. All reports are maintained confidentially.

Uploaded by

TOUSHIFAHEMED
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient’s Name:

UHID: IPID:
Age: Sex:
D.O.A: Unit:
CONTINUOUS QUALITY IMPROVEMENT (CQI) FORM

a. This form is for all near misses, adverse events, sentinel events.*
b. Kindly submit the form to unit quality office
c. This form is not part of patient’s medical record
d. The reporting is to ensure continuous quality improvement and is non-punitive in nature
e. All personnel should report on page-1 of the form within 24hrs of occurrence of an event
e. Supervisors/Managers should complete page-2 of the form within 48hrs of incident reporting
f. All category events must be analysed. Events in categories D to I must be subjected to root cause analysis
g. Confidentiality of the person reporting should be maintained
* Specific/ detailed forms for Transfusion Reaction/ Anesthesia Event/ Medication Error/HAPU/NSI to be completed by required personnel.
Date of event: Time of event: Holiday Week Day
Event occurred with:
 In-Patient  Visitor  Staff  Equipment / Property / Asset
 Out-Patient  Contractual Staff  Other (e.g. Spills etc.)
Location of event:
 In-Patient Area  Out-Patient  Any Other Area Specify location
Patient’s Diagnosis at admission (if applicable):

Description of event: (Brief description of the event - objective information only) - e.g. Due to slippery wet floor,
patient fell and broke a limb.

Any immediate correction and/or corrective action taken (Point wise and clear statement on what measures
were taken to correct the untoward event.) - e.g. fracture reduction done and wet floor was dried immediately.

Reported by staff / clinician (mention name / position / job title):

Reported by Patient / Attendant (Provide Name, Address and Phone Number)


Outcome (mention category) - to be filled by supervisor
 SENTINEL EVENTS
 Category A: Circumstances or events that have
the capacity to cause error
 Category F: Harm to the individual
 Category B: An error that did not reach the individual (lasting more than 2
weeks)
 Category C: An error that reached the individual  Category G: Permanent harm to the
but did not cause harm individual
 Category H: Intervention required to
sustain life
 Category D: An error that reached the individual and  Category I: Death of individual
 Category I: Death of the individual
required monitoring or intervention to confirm
that it resulted in no harm
 Category E: Harm to the individual (lasting less
than 2 weeks)
FOR CATEGORY D-I, QUALITY TO ATTACH RCA REPORT (AS RELEVANT) OR MENTION EXPECTED RCA
COMPLETION DATE HERE ______________

 REMAINING PART OF THIS FORM IS TO BE FILLED FOR CATEGORY A-C EVENTS ONLY ------
-------

Event Analysis Summary (Category A-C, to be filled in the box below by Supervisor / Unit Manager):

What factors contributed to the event? (To be filled by Supervisor / Unit Manager):
 Patient Issues  Negligence of Commission (wrong limb surgery)
 Staff Issues  Medication issues (dose, allergy, frequency issues, storage, formulation)
 Handover Issues  Prescription issues (illegible, not copied to drug book, wrong name)
 Communication Issues  Drug administrative issues (route, preparation, wrong site, drug quality)
 Skills Issues  Blood Safety Issues  Environmental Issues
 Judgmental Issues  Security & Safety Issues  System Failure
 Negligence of Omission  Legal Compliance Issues  Potential Risk
Actions required to prevent such an event in future (To be filled by Supervisors/ Unit Manager): For e.g. putting
railings in the area, notify "wet floors" while cleaning (always).

Department Head (Ensure the form is adequately completed. Document what steps have been taken)

Corrective and preventive action plan reported to:


 Support Service Head  Department Head where problem occurred
 Facility Director  Department Head who is responsible for action
 Medical Superintendent  Officer, patient, attendant who reported the event
 Chief of Nursing  Unit Quality Head

Name & Sign of Supervisor: Name & Sign of Department Head:

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