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  Real Critical Incident Reporting Form 
    

Your data consists of 301 critical incident reports from a given hospital, which may be viewed below. By clicking on the ">" or "<"  buttons, you may view either the next or previous report, respectively. By clicking on "|<<" or ">>|" you may start at either the beginning or end of the reports.

 

Hospital Effect of Incident
Incident Number    Actual Severity
Incident    Potential Severity
   Date and Time of Incident    Additional Days in Hospital
   Date and Time of Report    Additional Cost to Patient
   Type of Incident    Additional Cost to Hospital
   Location    Additional Treatment
   Department Staff Information
   Witnesses    Who Reported
Patient    Staff Condition
   Sex    Staff Training
   Age
   Type Prevention
   Physician Cause
   Prior Condition Description of the Incident
   Post Condition
   Pre-incident pain
   Post-incident pain
   Was patient and/or family notified of event?
   Diagnosis


Data Map

T1 - 1 Hospital Effect of Incident
T2 - 2 Incident Number T11 - 11    Actual Severity
Incident T12 - 12    Potential Severity
T3 - 3    Date and Time of Incident T14 - 14    Additional Days in Hospital
T4 - 4    Date and Time of Report T17 - 17    Additional Cost to Patient
V5 - 5    Type of Incident T18 - 18    Additional Cost to Hospital
V6 - 6    Location T19 - 19    Additional Treatment
V7 - 7    Department Staff Information
V8 - 8    Witnesses V12 - 12    Who Reported
Patient V13 - 13    Staff Condition
V9 - 9    Sex V30 - 30    Staff Training
T20 - 20    Age
V10 - 10    Type V23 - 23 Prevention
V29 - 29    Physician V27 - 27 Cause
V28 - 28    Prior Condition V26 - 26 Description of the Incident
V24 - 24    Post Condition
T21 - 21    Pre-incident pain
T22 - 22    Post-incident pain
V16 - 16    Was patient and/or family notified of event?
V25 - 25    Diagnosis

T1 - 1Hospital
T2 - 2Incident Number
T3 - 3Date and Time of Incident
T4 - 4Date and Time of Report
V5 - 5Type of Incident
V6 - 6Location
V7 - 7Department
V8 - 8Witnesses
V9 - 9Sex
V10 - 10Type
T11 - 11Actual Severity
T12 - 12Potential Severity
V12 - 12Who Reported
V13 - 13Staff Condition
T14 - 14Additional Days in Hospital
V16 - 16Was patient and/or family notified of event?
T17 - 17Additional Cost to Patient
T18 - 18Additional Cost to Hospital
T19 - 19Additional Treatment
T20 - 20Age
T21 - 21Pre-incident pain
T22 - 22Post-incident pain
V23 - 23Prevention
V24 - 24Post Condition
V25 - 25Diagnosis
V26 - 26Description of the Incident
V27 - 27Cause
V28 - 28Prior Condition
V29 - 29Physician
V30 - 30Staff Training

Author’s Note – While I have attempted to make this reporting form as realistic as possible, borrowing from different sources, its purpose is to generate simulated data useful for various types of statistical analysis and not for actual medical use.