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DOH-4461 Reportable Incident Form - New York State Department

DOH-4461 Reportable Incident Form - New York State Department-2025

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The document is a Reportable Incident Form from the New York State Department of Health's Bureau of Emergency Medical Services, which must be completed for any serious injury, illness, or death involving EMS providers, patients, or others. It outlines the necessary information to be reported within 5 business days and includes sections for general incident details, injured EMS crew members, patients, other emergency personnel or civilians, and vehicle information. The form emphasizes compliance with state regulations and does not replace other required incident reporting forms.

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What is an example of a serious reportable incident?

(A) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider. (B) The abduction of a patient of any age. (C) The sexual assault on a patient within or on the grounds of a health facility.

What is considered a reportable incident?

Reportable incidents are always severe in nature and include amputations, loss of an eye, in-patient hospitalization (admittance), and fatalities. Reporting these events may trigger an OSHA investigation process. Determining work relatedness of an injury or illness can be a challenging task.

What is a serious reportable incident report?

The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for docHub learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for

What are the reportable incidents?

Reportable incidents are serious incidents or alleged incidents which result in harm to an NDIS participant and occur in connection with NDIS supports and services. Specific types of reportable incidents include: The death of a person with disability.

What is a serious incident report?

A LEVEL ONE Serious Incident is the most severe type of incident. A level one incident must include at least one of the following: Any event that has been reported in the media current or recent past regardless of type of incident. The event has resulted in a death or serious physical injury on the programs premises.

What is an example of a serious reportable event?

The occurrence of a serious preventable adverse event in health caree.g., operating on the wrong patient or wrong body part or transfusing the wrong type of blood into a patientsuggests (but does not prove) that a flaw exists in the health care organizations efforts to safeguard patients.

How do I fill out a medical incident report?

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate responsecalling for help, for example, and notifying the patients physician.

Who fills out an incident report form?

Include small details and all pertinent data. The supervisor should verify the information in the report. Only the person that is directly involved in the incident can fill out the form. Be thorough and avoid making corrections.

DOH-4461 Reportable Incident Form - New York State Department-2025

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