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Confidential Clinical Concern Report

FACTS
Organization:
Department:
Is a patient involved?
Medical Record Number:
Is there an alleged injury?
Name of employee(s) involved:
Witness(es):
ANALYSIS
Describe in your own words the clinical concern or the event causing concern:
Mark the factors that may have contributed to the concern or event (check all that apply)
Communication among staff of same group Communication with Patient
Communication with support units Absence of policy/procedure
Communication between groups Knowledge, understanding, ability
Handoff/Transition of Care Medication error
Supervision Scope of practice
Professionalism
Resources
Limitation of therapeutic/diagnostic standards
Lack of equipment/wrong equipment/equipment failure
Known complication; standard of care met and care appropriate
Other
What could possibly have prevented this incident?
CONCLUSIONS
Proposed Solutions?
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PRIVILEGED PEER REVIEW AND RISK MANAGEMENT DOCUMENT PURSUANT TO STATUTE. THIS INFORMATION SHOULD NOT BE DISCLOSED FOR ANY PURPOSE OTHER THAN PEER REVIEW OR RISK MANAGEMENT/QUALITY ASSURANCE.
 
Please contact Amy Sokol at 8-7283 if you have questions regarding this form.