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Incident Report
Incident Report
Please fill out completely the form below to generate the Incident Report.
All fields with asterisk (*) are required.
Patient/Non Patient:
*
Patient
Non Patient
Facility:
Select One
Children's Hospital of Michigan
Detroit Receiving Hospital/University Health Center
DMC Other
Harper University Hospital/Hutzel Women's Hospital
Huron Valley-Sinai Hospital
Rehabilitation Institute of Michigan
Sinai-Grace Hospital
Location:
Select One
CHM-4SWE
CHM-5NEA
CHM-5SEA
CHM-5WES
CHM-605-5NWE
CHM-6EAS
CHM-6WES
CHM-ADMITTING/REGISTRATION
CHM-ADOLESCENT MED - CARL'S BLDG
CHM-ADOLESCENT MED-ETKIN SPECIALTY
CHM-ADOLESCENT MEDICINE - BIRMINGHAM
CHM-ADOLESCENT MEDICINE OAKLAND CENTER
CHM-ADOLESCENT MEDICINE-NOVI
CHM-ADOLESCENT MED-PED SPEC CTR
CHM-ADOLESCENT TRANSITION CLN-UHC
CHM-AFSCME FRIENDS AND FAMILY CHM
CHM-AFTER HOURS KID CARE - LAHSER,CHM-ALLERGY - 5TH FL CARL'S BLDG
CHM-ALLERGY - BIRMINGHAM
CHM-ALLERGY - STILSON
CHM-ALLERGY CLINIC - NOVI
CHM-ALLERGY CLINIC - PORT HURON
CHM-ALLERGY CLINIC-ALEX J ETKIN
CHM-ALLERGY- PED SPEC STR
CHM-AMBULATORY SAME DAY SURGERY
CHM-AMBULATORY INFUSION CENTER
CHM-AMBULATORY INFUSION CTR- PEDS
CHM-AMBULATORY METABOLIC DEV- PED
CHM-AMBULATORY METABOLIC DEVELOPMENT
CHM-AMBULATORY PEDS-5TH FL CARL'S
CHM-AMBULATORY SURGERY - DSH
CHM-ANESTHESIA
CHM-ANESTHESIA PROCEDURE UNIT
CHM-APNEA-2ND FLR SPEC,CARL'S BLDG
CHM-AUDIOLOGY - PLYMOUTH
CHM-AUDIOLOGY LAHSER SITE
CHM-AUDIOLOGY-ALEX J. ETKIN SPEC CENTER
CHM-AUDIOLOGY-CLINTON TWSHP STILSO
CHM-AUDIOLOGY-N.E.SPECIALTY CTR
CHM-AUDIO-S&
H,MCCDC-3RD FL CARL'S
CHM-AUTISM CENTER NOVI
CHM-BEHAVIORAL LEARNING - NOVI
CHM-BEHAVIORAL LEARNING-MARYSVILLE
CHM-BEHAVIORAL LEARNING-STILSON
CHM-BLOOD BANK
CHM-BONE MARROW TRANSPLANT
CHM-BREATHMOBILE
CHM-BRONCHOPULMONARY DYSPLASIA
CHM-CAFETERIA
CHM-CAMPBELL ELEMENTARY SCHOOL BASED CLINIC
CHM-CARDIAC CATH
CHM-CARDIOLOGY ANN ARBOR-YPSI, MI
CHM-CARDIOLOGY CRITTENTON- ROCHESTER, MI
CHM-CARDIOLOGY MACHD-HARP PROF BLD
CHM-CARDIOLOGY-TRENTON
CHM-CARDIOVASCULAR SURGERY
CHM-CAT SCAN
CHM-CHILD ASS.DEVL PEDS-II, CARL'S
CHM-CHILD ASSESS - OAKLAND/LAHSER
CHM-CHILD PROTECTION CENTER
CHM-CRANIOFACIAL CLEFT LIP/PALATE
CHM-CRD-BLOOMFIELD HILLS SPCLTY CENTER
CHM-CSP
CHM-CT SCAN-STILSON CTR CLINTN TWP
CHM-DAY TREATMENT CENTER
CHM-DERMATOLOGY - CARLS BLDG
CHM-DERMATOLOGY- PED SPEC CTR
CHM-DEVELOPMENTAL ASSESSMENT CLINIC
CHM-DEVELOPMENTAL ASSESSMENT CLINIC
CHM-DIABETES - ETKIN SPECIALTY CTR
CHM-DIABETES – PEDS SPEC CTR
CHM-DIABETES SVCS-2ND FL CARL'S
CHM-DIABETIC SVCS - OAKLAND/LAHSER
CHM-DIAGNOSTIC IMAGING - BIRMINGHA
CHM-DIAGNOSTIC IMAGING NOVI
CHM-DIAGNOSTIC IMAGING-DSH
CHM-DIAGNOSTIC RADIOLOGY – CANTON
CHM-DIALYSIS- PED SPEC CTR
CHM-DMC FRIENDS AND FAMILY EMPLOYE
CHM-EEG - CANTON
CHM-EEG - DEARBORN HEIGHTS
CHM-EEG Bloomfield Hills
CHM-EEG STILSON CTR-CLINTON TWNSHP
CHM-EEG West Bloomfield
CHM-EEG-ETKIN SPECIALTY CENTER
CHM-ELECTROENCEPHOLOGRAMS
CHM-ELECTRONEURODIAGNOSTIC SERVICES 3RD FLR RM 3B110
CHM-ELECTRONEURODIAGNOSTICS- NOVI
CHM-EMERGENCY DEPARTMENT
CHM-EMERGENCY DEPARTMENT RESEARCH
CHM-EMERGENCY TRAUMA
CHM-ENDOCRINOLOGY - OAKLAND/LAHSER
CHM-ENDOCRINOLOGY -2ND FL CARLS
CHM-ENDOCRINOLOGY- PED SPEC CTR
CHM-ENDOCRINOLOGY-ETKIN SPECIALITY
CHM-ENDOCRINOLOGY-WEST BLOOMFIELD
CHM-ENT - CARL'S BUILDING
CHM-ENT- ALEX J. ETKIN SPECIALTY CT
CHM-ENT CLINIC - PLYMOUTH
CHM-ENT- MACOMB
CHM-FRIENDS AND FAMILY PROGRAM CHM
CHM-GASTROENTEROLOGY - CANTON
CHM-GASTROENTEROLOGY - HCC NOVI
CHM-GASTROENTEROLOGY – PEDS SPEC CTR
CHM-GASTROENTEROLOGY - PORT HURON
CHM-GASTROENTEROLOGY HURON VALLEY
CHM-GASTROENTEROLOGY-2ND FLR CARLS
CHM-GASTROENTEROLOGY-ETKIN SPECIAL
CHM-GASTROENTEROLOGY-OAKLAND/LAHSE
CHM-GASTROENTEROLOGY-WEST BLOOMFIELD
CHM-GENERAL CLINICAL RESEARCH
CHM-GENERAL PEDICATRICS – PEDS SPEC CTR
CHM-GENETIC SCREENING - UHC
CHM-GENETIC/METABOLIC DISOR-LAHSER
CHM-GENETICS – PEDS SPEC CTR
CHM-GENETICS AND METABOLIC DEVELOPMENT
CHM-GENETICS/METABOLIC DISORDERS
CHM-GI - STILSON
CHM-GI BIRMINGHAM
CHM-GI BLOOMFIELD HILLS SPCLTY CTR
CHM-GIFT SHOP
CHM-GRANT STUDY PROGRAM CHM
CHM-GSEA
CHM-HAMTRAMCK SCHOOL BASED CLINIC
CHM-HEART TRANSPLANT PROGRAM
CHM-HEMATOLOGY/ ONCOLOGY
CHM-HEMATOLOGY/ONCOLOGY STILSON CTR
CHM-HEMODIALYSIS
CHM-HORIZONS IMMUNOLOGY CLINIC
CHM-HOSPITAL GROUNDS
CHM-IMMUNIZATION STA CHM PED SPEC CTR
CHM-IMMUNOLOGY 5F UHC
CHM-IMMUNOLOGY-5TH FL CARL'S BLDG
CHM-INFECTIONUS DISEASE
CHM-INFECTIOUS DISEASE – PEDS SPEC CTR
CHM-INTENSIVE CARE TRANSPORT TEAM
CHM-INTESTINAL REHAB PROGRAM
CHM-KID CARE EMERGENCY DEPARTMENT
CHM-KIDNEY PRE-TRANSPLANT
PEDIATRIC SPECIALTY CENTER
CHM-KIDS EARS HEARING- ETKINS
CHM-KIDS HEARING AIDS
CHM-LAB SERVICES – PEDS SPEC CTR
Incident Date:
*
MM/DD/YYYY
Incident Time:
HH:
Select One
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
16
17
18
19
20
21
22
23
MM:
Select One
0
5
10
15
20
25
30
35
40
45
50
55
FIN:
*
Patient Name:
*
Birthdate:
*
MM/DD/YYYY
Incident Type:
Select One
BLOOD-ADMINISTRATION
BLOOD-ADVERSE REACTION
BLOOD-CONSENT
BLOOD-DEVICE
BLOOD-DISPENSING
BLOOD-MISLABELED
BLOOD-ORDER
BLOOD-OTHER
BLOOD-PRODUCT
BLOOD-RESULTS
BLOOD-SPECIMEN/REQUISITION NOT SIGNED
CARE MGMT-ADVANCE DIRECTIVES NOT FOLLOWED
CARE MGMT-ALLERGIC REACTION EXCLUDING BLOOD.
CARE MGMT-ASPIRATION
CARE MGMT-BURN
CARE MGMT-CELLULITIS IN ABSENSE OF IV
CARE MGMT-CRUSHING INJURY
CARE MGMT-DIET OR NUTRITION EVENT
CARE MGMT-DVT/PE NOT POA AS A COMPLICATION ..
CARE MGMT-DVT/PE NOT POA NOT AS A COMPLICAT.
CARE MGMT-ELECTRICAL INJURY
CARE MGMT-ELOPEMENT
CARE MGMT-EVALUATION OR ASSESSMENT ISSUE
CARE MGMT-EYE INJURY
CARE MGMT-GLYCEMIC EVENT DURING ADMISSION
CARE MGMT-HANDOFF COMMUNICATION ISSUE
CARE MGMT-HEMORRHAGE (NOT RELATED TO CHILDB.
CARE MGMT-IMPACT OR COLLISION
CARE MGMT-INJECTION SITE INJURY (EXCLUDING ..
CARE MGMT-INTERPRETER ISSUE
CARE MGMT-IV INSERTION, PLACEMENT, OR MANAG.
CARE MGMT-NEEDLESTICK INJURY
CARE MGMT-OTHER
CARE MGMT-PATIENT IDENTIFICATION
CARE MGMT-PATIENT LEFT
CARE MGMT-PATIENT MONITORING
CARE MGMT-PATIENT TRANSPORT ISSUE
CARE MGMT-PATIENT/FAMILY REFUSAL
CARE MGMT-RESTRAINT/SECLUSION USE CAUSING I.
CARE MGMT-SKIN INJURY (EXCLUDING PRESSURE U.
CARE MGMT-TRANSFER OR DISCHARGE ISSUE
CARE MGMT-TREATMENT ISSUE
CARE MGMT-UNEXPECTED CODE ARREST
CARE MGMT-UNPLANNED READMISSION
CARE MGMT-VASCULAR COMPLICATION
CARE MGMT-WRONG PATIENT
DEV/EQUIP-COMBINATION(EQUIP/OPERATOR)
DEV/EQUIP-OTHER
DEV/EQUIP-PRODUCT/SUPPLY
DIALYSIS - ACCESS
DIALYSIS - BLOOD LOSS
DIALYSIS - COMPLICATIONS
DOC-DELAYED
DOC-INCORRECT
DOC-INSUFFICIENT
DOC-LOST MEDICAL RECORD
DOC-MULTIPLE MRNS
DOC-OMITTED
DOC-PAGES MISSING
EOC-DIETARY ISSUES
EOC-FACILITY ISSUES,
EOC-HOUSEKEEPING
EOC-NOISE
EOC-OTHER ENVIROMENTAL
EOC-SMOKING
EOC-TELEPHONE
EOC-TV SERVICE
EQUIP EQUIPMENT ALERT
EQUIP EQUIPMENT DEFECT
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