Commonwealth of Massachusetts
Board of Registration in Medicine
Patient Care Assessment Division
Major Incident Report Form

(revised 3/99)

Incident Report Links

	Major Incident Instructions

	Basis Codes

I. REPORT IDENTIFICATION

Check if Initial Report:

Check if Follow-up Report:

If this is a follow-up report, indicate date of initial report:

II. REPORTING HEALTH CARE FACILITY

Name of Facility :

Address:

Report completed by:

Title:

Telephone Number:

Date report completed:

Signature: ______________________________________________________

III. DATE AND LOCATION OF INCIDENT

Date of Incident:

Incident Location:

IV. PATIENT(S) INVOLVED IN INCIDENT

Patient 1

Date of Birth:

Sex: Female: Male:

Date of Admission or Presentation:

Admitting (or Presenting) Diagnosis(es):

Patient 2

Date of Birth:

Sex: Female: Male:

Date of Admission or Presentation:

Admitting (or Presenting) Diagnosis(es):

V. FACILITY STAFF INVOLVED IN INCIDENT

A. Physician(s) Involved in Incident

[* items are optional for this section only]

1) Name*:

License No.*:

Specialty:

Relationship to Patient:

2) Name*:

License No.*:

Specialty:

Relationship to Patient:

3) Name*:

License No.*:

Specialty:

Relationship to Patient:

B. Non-Physician(s) Involved in Incident

1) Relationship to Patient

2) Relationship to Patient:

3) Relationship to Patient:

VI. TYPE OF INCIDENT

A. Indicate one of the four types of major incident:

Type 1. Maternal death related to delivery.

Type 2. Death in the course of, or resulting from, elective ambulatory procedure.

Type 3. An invasive diagnostic procedure or surgical intervention performed on the
wrong organ, extremity, or body part.

Type 4. Death or major or permanent impairment of bodily function that was not
ordinarily expected as a result of the patient’s condition on presentation.

B. For either a Type 3 or Type 4 major incident, check one of the following:

Disability: Temporary: Permanent:

Death:

Other: If other, please explain:

VII. NATURE OF INCIDENT

A. Provide the basis code(s) that best describe(s) the incident reported. Basis codes are found in Table III. Choose as many as apply, but no more than ten.

1) 2)

3) 4)

5) 6)

7) 8)

9) 10)

B. Narrative Description of Major Incident

In the space below or in an attachment, provide a description of the incident. Additional pages may be used.

VIII. INTERNAL INVESTIGATION

A. Complete either (1) or (2):

1) Open internal investigation:

Date scheduled to be completed:

2) Internal investigation completed:

Date completed:

B. Results of Internal Investigation

In the space below or in an attachment, provide the results of the internal investigation. Additional pages may be used.

IX. CORRECTIVE MEASURES

A. No corrective measures taken:

If no corrective measures were taken, explain why not below. Additional pages may be used.

B. If corrective measures were taken prior to the completion of the internal investigation, describe them in the space below. Additional pages may be used.

C. If corrective measures were taken following the completion of the internal investigation, describe them in the space below. Additional pages may be used.

Commonwealth of Massachusetts Board of Registration in Medicine Patient Care Assessment DivisionMajor Incident Report Form

Commonwealth of Massachusetts
Board of Registration in Medicine
Patient Care Assessment Division
Major Incident Report Form