CLINICAL INCIDENT REPORT
INCIDENT DETAILS
Date / Time:March 12, 2026 · 06:15
Location:Ward 3A Cardiology — Bed 8
Incident Type:Patient Fall — Unwitnessed
PATIENT DETAILS
Patient:John Davis · Age 72
Admitting Diagnosis:Acute coronary syndrome
DESCRIPTION OF INCIDENT
What happened:Patient found on floor beside bed at 06:15 during routine morning rounds. Unwitnessed fall. Patient alert and orientated on assessment. Small laceration noted to right forearm approximately 3cm, no active bleeding. Denied head strike. No loss of consciousness reported.
IMMEDIATE ACTIONS TAKEN
Actions:Patient assisted back to bed. Wound assessed and dressed. Vital signs checked — BP 138/82, HR 76, GCS 15/15. On-call physician Dr. Martinez notified at 06:22. Family contacted at 06:35. Fall risk assessment updated. Bed rails raised bilaterally. Call bell repositioned within reach.
CONTRIBUTING FACTORS
Identified factors:Bed rails found in lowered position. Call bell noted out of patient reach. Patient had consumed diuretic medication at 22:00 previous evening.
OUTCOME & FOLLOW-UP
Patient outcome:Minor laceration dressed and monitored. No fractures suspected. Neurological observations commenced hourly for 4 hours per protocol.
Reported by:RN Sarah Johnson · Shift Supervisor notified