{% extends "base.html" %} {% load static %} {% block title %} {% if form.instance.pk %}Edit Incident{% else %}Report New Incident{% endif %} - Quality Management {% endblock %} {% block content %}

{% if form.instance.pk %} Edit Incident {{ form.instance.incident_number }} - {{ form.instance.title }} {% else %} Report New Incident Quality and Safety Incident Reporting {% endif %}

Incident Information

Patient Safety Notice

This form is for reporting quality and safety incidents. All information will be treated confidentially and used for quality improvement purposes. If this is a medical emergency, please call 911 immediately.

{% csrf_token %}
Basic Information
{{ form.title }} {% if form.title.errors %}
{{ form.title.errors.0 }}
{% endif %}
Brief, descriptive title of the incident
{{ form.category }} {% if form.category.errors %}
{{ form.category.errors.0 }}
{% endif %}
Type of incident category
{{ form.incident_type }} {% if form.incident_type.errors %}
{{ form.incident_type.errors.0 }}
{% endif %}
Specific type of incident
{{ form.occurred_at }} {% if form.occurred_at.errors %}
{{ form.occurred_at.errors.0 }}
{% endif %}
When did the incident occur?
{{ form.severity }} {% if form.severity.errors %}
{{ form.severity.errors.0 }}
{% endif %}
Impact severity level
{{ form.priority }} {% if form.priority.errors %}
{{ form.priority.errors.0 }}
{% endif %}
Response priority level
{{ form.status }} {% if form.status.errors %}
{{ form.status.errors.0 }}
{% endif %}
Current incident status
Location & Assignment
{{ form.department }} {% if form.department.errors %}
{{ form.department.errors.0 }}
{% endif %}
Department where incident occurred
{{ form.location }} {% if form.location.errors %}
{{ form.location.errors.0 }}
{% endif %}
Room number, area, or specific location
{{ form.reported_by }} {% if form.reported_by.errors %}
{{ form.reported_by.errors.0 }}
{% endif %}
Person reporting the incident
{{ form.assigned_to }} {% if form.assigned_to.errors %}
{{ form.assigned_to.errors.0 }}
{% endif %}
Person responsible for investigation
Incident Description
{{ form.description }} {% if form.description.errors %}
{{ form.description.errors.0 }}
{% endif %}
Provide a detailed description of what happened. Include who, what, when, where, and how.
{{ form.immediate_action_taken }} {% if form.immediate_action_taken.errors %}
{{ form.immediate_action_taken.errors.0 }}
{% endif %}
Describe any immediate actions taken to address the incident
Patient Involvement
{{ form.patient_involved }} {% if form.patient_involved.errors %}
{{ form.patient_involved.errors.0 }}
{% endif %}
{{ form.patient_harm }} {% if form.patient_harm.errors %}
{{ form.patient_harm.errors.0 }}
{% endif %}
{% if form.instance.pk and form.instance.status != 'open' %}
Investigation Details
{{ form.investigator }} {% if form.investigator.errors %}
{{ form.investigator.errors.0 }}
{% endif %}
Person conducting investigation
{{ form.root_cause_analysis }} {% if form.root_cause_analysis.errors %}
{{ form.root_cause_analysis.errors.0 }}
{% endif %}
{{ form.investigation_findings }} {% if form.investigation_findings.errors %}
{{ form.investigation_findings.errors.0 }}
{% endif %}
Summary of investigation findings
{{ form.root_cause }} {% if form.root_cause.errors %}
{{ form.root_cause.errors.0 }}
{% endif %}
Identified root cause of the incident
{{ form.contributing_factors }} {% if form.contributing_factors.errors %}
{{ form.contributing_factors.errors.0 }}
{% endif %}
Factors that contributed to the incident
{% endif %} {% if form.instance.pk and form.instance.status in 'resolved,closed' %}
Resolution
{{ form.resolution_summary }} {% if form.resolution_summary.errors %}
{{ form.resolution_summary.errors.0 }}
{% endif %}
Summary of how the incident was resolved
{{ form.lessons_learned }} {% if form.lessons_learned.errors %}
{{ form.lessons_learned.errors.0 }}
{% endif %}
Key lessons learned from this incident
{% endif %}
Attachments
Upload photos, documents, or other relevant files. Maximum 10MB per file.
{% if form.instance.pk and form.instance.attachments.exists %}
Existing Attachments:
{% for attachment in form.instance.attachments.all %}
{{ attachment.filename }} {{ attachment.file_size|filesizeformat }}
{% endfor %}
{% endif %}

Reporting Guidelines

What to Report:
  • Patient safety events
  • Medication errors
  • Falls and injuries
  • Equipment failures
  • Near misses
  • Security incidents
Severity Levels:
  • Critical Death or severe harm
  • High Moderate harm
  • Medium Minor harm
  • Low No harm
Priority Levels:
  • Urgent Immediate action
  • High Within 24 hours
  • Medium Within 72 hours
  • Low Within 1 week

Help & Support

Quality Department:
(555) 123-4567
quality@hospital.com
Patient Safety:
(555) 123-4569
safety@hospital.com
Emergency:
911 or (555) 123-4911

Form Tips

  • Be specific and factual
  • Include all relevant details
  • Attach supporting documents
  • Use objective language
  • Save drafts frequently
{% endblock %} {% block js %} {% endblock %}