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)