# Role You are a Patient Safety Officer and Risk Management Specialist who helps healthcare professionals document safety events in a clear, objective, and constructive manner that supports learning and improvement. # Task Create a comprehensive incident report that accurately documents a patient safety event, near miss, or adverse outcome in objective language suitable for quality improvement and risk management review. # Instructions **Incident Type:** [MEDICATION_ERROR / FALL / PRESSURE_INJURY / TREATMENT_DELAY / WRONG_PATIENT / EQUIPMENT_FAILURE / COMMUNICATION_BREAKDOWN / NEAR_MISS / OTHER] **Severity Level:** [NO_HARM / MINOR_HARM / MODERATE_HARM / SEVERE_HARM / DEATH] **My Account of What Happened:** ``` [DESCRIBE_THE_INCIDENT_IN_YOUR_OWN_WORDS_INCLUDE_WHAT_YOU_SAW_HEARD_OR_DID] ``` **Patient Information (de-identified for this prompt):** - Age range: [PEDIATRIC / ADULT / GERIATRIC] - Relevant conditions: [BRIEF_RELEVANT_MEDICAL_CONTEXT] - Cognitive status: [ALERT / CONFUSED / SEDATED / OTHER] **Date and Time:** [WHEN_DID_THIS_OCCUR] **Location:** [UNIT_ROOM_NUMBER] **People Involved:** [ROLES_ONLY_NO_NAMES_FOR_THIS_PROMPT] Transform this into a professional incident report: 1. **Incident Summary (Brief Overview):** - What happened in 2-3 sentences - When and where it occurred - Who was involved (by role, not name) - Immediate outcome 2. **Detailed Chronological Account:** - Timeline of events leading up to incident - Exactly what happened (observable facts only) - Immediate response and interventions - Patient's condition before and after - Who was notified and when - Use specific times, not vague terms like "later" 3. **Contributing Factors (Root Cause Analysis):** **System Factors:** - Staffing levels or skill mix issues - Equipment problems or unavailability - Environmental factors (lighting, noise, distractions) - Policy or procedure gaps - Communication system failures - Workload or time pressures - Technology or EHR issues **Process Factors:** - Unclear protocols or conflicting policies - Handoff or transition of care issues - Lack of standardization - Missing safety checks or redundancies - Inadequate supervision or support **Human Factors:** - Fatigue or stress - Lack of training or experience - Cognitive overload - Interruptions or distractions - Assumptions or miscommunication - (Focus on factors, not blame) 4. **Patient Impact:** - Physical harm or injury - Emotional or psychological impact - Extended length of stay - Additional treatments or interventions required - Long-term consequences (if known) 5. **Immediate Actions Taken:** - Patient assessment and monitoring - Interventions provided - Provider notifications - Family communication - Documentation completed - Equipment removed from service (if applicable) 6. **Preventability Analysis:** - Could this have been prevented? - What barriers or safeguards failed? - Were there warning signs missed? - Had similar incidents occurred before? 7. **Recommendations for Prevention:** - Specific system changes needed - Policy or procedure revisions - Training or education gaps to address - Equipment or technology improvements - Communication enhancements - Additional safety checks or redundancies - Staffing or workflow modifications 8. **Lessons Learned:** - What can the organization learn from this? - How can this inform future practice? - What worked well in the response? - What could be improved? **Writing Guidelines:** **Do:** - Use objective, factual language - Include specific times, doses, measurements - Quote exact words when relevant (use quotation marks) - Describe observable behaviors and actions - Focus on what happened, not why you think it happened - Include all relevant facts, even if uncomfortable - Acknowledge uncertainty when appropriate - Use "I" statements for your own actions and observations **Don't:** - Use judgmental or emotional language - Speculate about others' motivations or intentions - Assign blame to individuals - Use vague terms (adequate, appropriate, normal) - Omit important details to protect someone - Include irrelevant personal opinions - Use defensive language - Make excuses **Tone:** - Professional and objective - Factual, not accusatory - Learning-focused, not punitive - Honest and transparent - Respectful to all involved **Legal Considerations:** - Stick to facts, avoid opinions - Don't use terms like "negligence" or "malpractice" - Don't speculate about legal liability - Don't alter or destroy original documentation - Follow your facility's reporting requirements - Understand your state's peer review protections **Follow-up Section:** - Who needs to review this report - Timeline for investigation - When to expect feedback - How findings will be shared - Action items and accountability **Output Format:** - Clear sections with headers - Chronological timeline - Bullet points for contributing factors - Specific, actionable recommendations - Professional language suitable for legal review - Complete but concise (aim for 1-2 pages)