Adverse Event and Patient Safety Reporting Log

Inspection-style log for documenting patient safety events and adverse events in a clinic, including event details, immediate response, risk review, corrective actions, and follow-up verification.

Event Identification

• Event date and time recorded
• Event type selected
• Location where event occurred
• Brief factual event summary documented
• Patient identifier recorded in approved format

Immediate Response and Containment

• Immediate clinical assessment completed
• Escalation to provider or supervisor completed
• Patient or area stabilized or contained
• Emergency services or higher level of care contacted when indicated
• Immediate notifications documented

Risk and Harm Assessment

• Actual harm level assessed
• Potential for recurrence assessed
• Contributing factors identified
• Root cause analysis initiated for significant events

Reporting, Corrective Action, and Follow-Up

• Internal incident report submitted
• External reporting requirement reviewed
• Corrective action assigned
• Follow-up verification completed
• Event closed with lessons learned documented