Complete this the same day as the incident. When you submit, it goes to your supervisor and the leadership team and is saved to the incident file.
Emergency happening now? Call 911 first and keep everyone safe. File this report after.
Check everything that applies.
Safety and behavior
Health and clinical
Abuse, rights, and privacy
Building and property
Anything else
About the death
About the abuse or neglect concern
Report suspected abuse to DCS (children, 1-800-800-5556) or Adult Protective Services (1-800-992-6978) right away. That’s required by law and separate from this form.
About the medication error
These match the client safety event levels in policy 03.003. Leadership decides what needs to be reported to the state.
Use first name, last initial, and record number only. Don’t include diagnoses unless they matter to what happened.
Stick to facts: what you saw and heard, in order. Quote people’s words when they matter. Leave out opinions and guesses.
Outside help called (optional)
Steps taken to keep people safe, who you told and when, and what still needs to happen.
Who have you already told? (optional)
Sent to your supervisor and the leadership team. High-risk incidents get a team debrief within 24 hours.
Your supervisor and the leadership team have it now. Someone may follow up with questions.
If this was hard to be part of, it’s okay to step away for a few minutes. Staff wellness has a quick breathing exercise and people to talk to.
