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ASC incident report template

A one-to-two page incident report for surgery centers. It records the patient, procedure, phase of care and harm level. It also logs who was told and when, plus a first review that feeds QAPI. Staff fill in the facts during the shift. The manager decides how deep to investigate.

Updated Oct 5, 20268 sectionsFree to print
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Before you start

When to use it

  • A patient is hurt, or nearly hurt, before, during or after a procedure: a fall, burn or drug event.
  • A surgical safety event: wrong site, side, patient, procedure or implant, a retained item, or a count that does not match.
  • A patient is sent to a hospital, or admitted, unexpectedly after the procedure.
  • Equipment fails while in use on a patient, including events that may need an FDA report.
  • A near miss: an error caught at the time-out, count or scan, before it reached the patient.

How to fill it out well

  1. Finish sections 1 to 4 before the shift ends. The manager completes sections 5 to 7.
  2. Write what you saw: times, what was said, what equipment was in use. Skip guesses about why.
  3. Record time-out and count status even when normal. They show which safeguards ran.
  4. Secure the equipment, implants, vials and packaging. Tag any device and keep it out of use.
  5. Chart clinical facts in the medical record. Keep this report separate. Ask counsel how your state treats incident reports.
  6. Send it to the risk or quality lead within your policy window. Set the investigation level that day.

ASC incident report template

Organization: ______________________   Site: ______________________

1. Event details
Facility and locationRoom or area, such as OR 2, PACU bay 4 or pre-op.
Date of event
Time of eventYour best guess is fine. Say so in the story.
Time the event was foundLeave blank if the same. A count error found in recovery is later.
Event typePick the closest fit. Add detail in the story.FallBurn or fireMedication eventWrong site, side, patient, procedure or implantRetained item or count mismatchPositioning or pressure injuryEquipment or device eventUnplanned transfer or admissionInfection concernAnesthesia or airway eventSpecimen eventBehavior or securityOther
Reported by (name and role)
2. Patient and procedure
Patient name or medical record numberUse only what policy allows. Treat this page like a chart.
Patient date of birth
Scheduled procedure
Procedure done, if different
Proceduralist and anesthesia providerNames or roles, per policy. The review looks at the system.
Anesthesia typeNone or local onlyModerate sedation or MACRegional or neuraxialGeneralNot applicable
ASA physical statusIIIIIIIVNot recorded
3. Where in the case it happened
Phase of careScheduling or pre-arrivalRegistration and pre-opTime-out and prepProcedureEmergence from anesthesiaPACU or phase II recoveryDischargeAfter discharge (call-back or return)Non-patient area
Time-out done before the procedure?YesNoNot applicable
Counts (sponge, sharps, instruments) matched at close?If off, record who was told, how it was settled, and any imaging.YesNo: see storyNot applicable
Equipment or device involvedName, model, serial or lot number. Tag it and pull it from use.
Medication, implant or specimen involved
Did the event reach the patient?Report near misses too. They show a safeguard that worked.YesNo: caught before it reached the patient (near miss)
4. What happened
Description of the eventWhat you saw and did, in order. Facts only, no blame.
Immediate actions takenCare given, equipment secured, procedure stopped or finished, who was called.
Patient condition after the eventVital signs, symptoms, exam findings and any change from before.
Witnesses and others presentName and role. Collect written statements apart from this form.
5. Outcome and harm
Harm levelUse your harm scale, such as AHRQ Common Formats. Re-rate if the patient changes.No harmMild harmModerate harmSevere harmDeath
Additional care neededNoneExtra monitoring onlyTreatment in the ASCDelayed dischargeUnplanned transfer to a hospitalUnplanned hospital admission after dischargeRepeat or corrective procedure
Receiving hospital and transfer timeRecord call time, handoff and who accepted. CMS expects ASCs to track every transfer.
Possible sentinel or serious reportable eventIf yes, tell the administrator and risk lead now. Start a root cause analysis. Check state rules.
Possible device-related death or serious injuryASCs are device user facilities. Report deaths to the FDA and maker, and serious injuries to the maker, in 10 work days (21 CFR 803.30).
6. Notifications
Administrator or medical director told (name, date, time)
Surgeon or attending physician told (name, time)
Patient or representative informed (who, by whom, date, time)Write what was said and how the patient responded. Follow your disclosure policy.
Risk manager or quality lead told (name, date, time)
External reports made (state, accreditor, insurer, FDA)Write 'none' if none. Deadlines differ by state: check yours.
7. Initial review (manager)
Conditions seen that may have helped cause itList conditions, not people: staffing, schedule pressure, equipment, labeling, handoff, layout.
Preventable?Likely yesMaybeNoNot sure: needs investigation
Investigation levelManager reviewFocused investigationFull root cause analysis
Investigation owner and due date
Added to the QAPI event log
8. Sign-off
Completed by (name and title)
Signature of person completing the report
Manager or administrator review
Date reviewed
Editable copy

Get this template by email.

We send an editable version you can adapt to your policies, plus a short checklist. No patient information, ever.

Tips

  • Report near misses too. CMS expects ASCs to find errors caught before harm, since they signal future events.
  • Track every hospital transfer. CMS calls a single transfer a serious, unplanned outcome worth review.
  • Count events by phase of care each quarter. A cluster shows a weak safeguard.
  • Write conditions, not people. 'Count not matched before closing' says more than a name.

We use your details to respond to this request. No spam, and never any patient information in analytics.

Questions

About this template.

Something we missed? Ask us, and a person answers.

What is an incident report in a surgery center?

A same-day, factual record of an event that harmed or could have harmed a patient, visitor or staff member. It starts a review and feeds QAPI. Clinical facts stay in the medical record.

Does CMS require ambulatory surgery centers to track incidents?

In effect, yes. 42 CFR 416.43 requires an ASC to track adverse patient events, study causes and make improvements last. CMS says to at least track hospital transfers. Accreditors like AAAHC review these programs too.

Which events does CMS give as examples of ASC safety indicators?

CMS Appendix L lists patient burn, hospital transfer or admission, patient fall, wrong site, side, patient, procedure or implant, and timely prophylactic antibiotics. Centers may add other measures, and should add infection control.

Do surgery centers report device problems to the FDA?

Yes. Surgery centers are 'device user facilities' (21 CFR 803.3). Report device-related deaths to the FDA and the maker, and serious injuries to the maker (or the FDA if unknown), within 10 work days.

How does this template work in IncidentKit?

Staff describe the event by text. Lauren asks follow-up questions and drafts the fields, marked 'Lauren · draft' until a person reviews, edits and signs. The surgery center pack sets forms, routing and QAPI summaries.

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