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    Adverse Anaesthesia Event Form

    Uploaded by

    Harsh
    This document is an adverse anesthesia event form used to report any issues that occurred during or after surgery requiring anesthesia. It collects information on the patient, surgery details, location and timing of the event, associated medical conditions, treatments provided, and outcomes. The form is then analyzed and corrective and preventive actions are proposed and taken, such as changes to documentation, policies, training, or equipment. The actions are reviewed and approved by relevant managers and heads of the clinical services.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Adverse Anaesthesia Event Form

    Uploaded by

    Harsh
    341 views2 pages
    This document is an adverse anesthesia event form used to report any issues that occurred during or after surgery requiring anesthesia. It collects information on the patient, surgery details, location and timing of the event, associated medical conditions, treatments provided, and outcomes. The form is then analyzed and corrective and preventive actions are proposed and taken, such as changes to documentation, policies, training, or equipment. The actions are reviewed and approved by relevant managers and heads of the clinical services.

    Original Title

    ADVERSE ANAESTHESIA EVENT FORM

    Copyright

    © © All Rights Reserved

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    This document is an adverse anesthesia event form used to report any issues that occurred during or after surgery requiring anesthesia. It collects information on the patient, surgery details, location and timing of the event, associated medical conditions, treatments provided, and outcomes. The form is then analyzed and corrective and preventive actions are proposed and taken, such as changes to documentation, policies, training, or equipment. The actions are reviewed and approved by relevant managers and heads of the clinical services.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    341 views2 pages

    Adverse Anaesthesia Event Form

    Uploaded by

    Harsh
    This document is an adverse anesthesia event form used to report any issues that occurred during or after surgery requiring anesthesia. It collects information on the patient, surgery details, location and timing of the event, associated medical conditions, treatments provided, and outcomes. The form is then analyzed and corrective and preventive actions are proposed and taken, such as changes to documentation, policies, training, or equipment. The actions are reviewed and approved by relevant managers and heads of the clinical services.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Addressograph

    Patient’s Name____________________________________________________
    ADVERSE ANAESTHESIA
    Reg No ________________ IP No ____________ Age:_________ Date_________________
    EVENT FORM Time:______________ Gender:  M F
    Attending Consultant: ___________________________________________

    Name of Surgery:____________________________________________________________________________________________________________

    Speciality:-___________________________________________________________________________________________________________________

    Anaesthetist’s Name:-_______________________________________________________________________________________________________

    Surgery Date:-___________________________________________________ Time:______________________________

    Event Date:-_____________________________________________________ Time:______________________________

    Location of Event:-__________________________________________________________________________________________________________

     Type of Events & General condition of patient


    Type of Events Vitals
    ____________________________________________________________________________ ________________________________
    ____________________________________________________________________________ ________________________________
    ____________________________________________________________________________ ________________________________
     Associated Medical Illness
    _______________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________

     Treatment of Event
    _______________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________
     Outcome of Event
    _______________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________
    _______________________________________________________________________________________________________________________

    __________________________ _________________________________
    Name of attending Anesthetist Sign of Attending Anesthetist

    Comments:________________________________________________________________________________________
    __________________________________________________________________________________________________
    __________________________________________________________________________________________________

    Designation of person reporting the incident:_____________________________________________________________

    ______________________________________ ________________________________ ______________


    Name Sign Date

    ______________________________
    Sign of Responsible Manager
    Addressograph
    Analysis:-
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    Action advised or comments by Head Clinical Services

    Corrective Action:________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    Preventive Action:_______________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    Comments:________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________

    Name:-_______________________________________________________ Sign:-______________________ ______ Date:-________________


    Action advised by Committee:

    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________
    _____________________________________________________________________________________________________________________________________

    Actions Taken:-

    Documentation Changes Form Check list Charting Tool Other______________

    Policy & procedure Addition Implementation Revision

     Education/Training
     Information System Change
     Staffing Changes
     Disciplinary Action
     Equipment taken out of service
     Other____________________

    Action taken by

    Name: _______________________________________________________ Sign_________________________________________


    Designation: _________________________________________________ Date:_______________________________________

    _________________________________________ _________________________________________

    Name of Head Clinical Services Sign Head Clinical Services

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