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Nursing Commission Incident Report

Incident Report Form

To report injury, harm or near miss to a patient or client, complete the Nursing Commission Incident Report below.

AKA the critical incident report, this report is described on page 28 of the undergraduate student manual “…to report events involving a student or faculty member that the program has reason to believe resulted in patient harm, an unreasonable risk of patient harm, or diversion of legend drugs or controlled substances.” (WAC 246-840-513). When submitted via the online system, this report is directed to the “program director” the student indicates when completing the form.

Student name*
First Last
Enter your WSU student email address.*
Which program are you enrolled in?*
- BSN
- RN-BSN
- MN
- DNP
Which campus do you attend?*
- Spokane
- Tri-Cities
- Vancouver
- Yakima
Course number*
WSU Nursing instructors name*
First Last
Enter today's date.*
MM slash DD slash YYYY
Enter the date of the incident occured or was discovered.*
MM slash DD slash YYYY
Address of the facility (include name of the facility room number) where the incident occured.*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Did the error or near miss involve a medication?*
- Yes
- No
Enter the names of the other people who were involved in the incident.
Click the + sign to the right of each field to add additional names.
Name
Who did you notify about the incident? Enter the names here.*
Click the + sign to the right of each field to add additional names.
Briefly describe the error or near miss that occurred.*
Be detailed and keep to the facts. Include dates and times if known. If the incident was related to a medication, list the name of the medication, and the dose, time, and route of administration.
Contributing factors (cause and effect)*
Possible System Improvements*
In your opinion, are there system improvements that could be made that might help someone else avoid this error or near miss in the future?
Change in Personal Practice*
How will you change your practice to avoid this incident from occurring again in the future?

Washington State University acknowledges that its locations statewide are on the homelands of Native peoples, who have lived in this region from time immemorial. Currently, there are 42 tribes, 35 of which are federally recognized that share traditional homelands and waterways in what is now Washington State. Some of these are nations and confederacies that represents multiple tribes and bands. The University expresses its deepest respect for and gratitude towards these original and current caretakers of the region. As an academic community, we acknowledge our responsibility to establish and maintain relationships with these tribes and Native peoples, in support of tribal sovereignty and the inclusion of their voices in teaching, research and programming. Washington State University established the Office of Tribal Relations and Native American Programs to guide us in our relationship with tribes and service to Native American students and communities. We also pledge that these relationships will consist of mutual trust, respect, and reciprocity.

WSU's land acknowledgement

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Nursing Commission Incident Report

Incident Report Form

To report injury, harm or near miss to a patient or client, complete the Nursing Commission Incident Report below.

Name

Incident Report Form

To report injury, harm or near miss to a patient or client, complete the Nursing Commission Incident Report below.

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