Clinical Incidents Form - Lawrence S. Bloomberg Faculty of Nursing

The safety of Lawrence S. Bloomberg Faculty of Nursing students in clinical education settings is a high priority and the Faculty strives to provide students with safe and quality learning experiences. When an injury or incident occurs in the clinical setting, it is important that students complete and submit an online Clinical Incidents Form as soon as possible after the injury or incident. The submission will be reviewed by the Clinical Education Office in collaboration with Faculty, and both the student and Clinical Instructor/Preceptor will be contacted with further instructions to ensure the student receives appropriate care and follow-up.

Program**

Student Name

First NameLast Name

Email*

Confirmation EmailMUST be your UTORONTO email address

Date of Incident

Date

Course Code*

Other Course Code

Please enter your Course Code

Term*

Site and Unit*

Clinical Instructor/Preceptor Name*

Identify the incident *

Please further select from the drop-down menus below that correspond to the incident identified.

Other

Exposure to bodily fluids

Other

Physical Injuries

Other

Violence

Violence: Other

Medication Errors

Medication: Other

Procedure Error

Procedure: Other

Administrative Error

Admin Error: Other

Near Misses

Near Misses: Other

Describe circumstances of the incident (time, location, description)*

What was the follow up for this incident?*

Was an agency incident report completed?*

Any additional follow up required?*

Who is completing this form?*

Full name of individual completing this form:*

WSIB and Non-WSIB Incidents

A Work Safety and Insurance Board (WSIB) claim must be made when the incident is a physical injury (e.g., needle stick, fainting, slipping, exposure, etc.). This requires documents to be completed by the student, the clinical instructor/preceptor and the placement organization’s occupational health department. Within 48 hours of the injury, the clinical instructor/preceptor and student complete the University of Toronto Students on Unpaid Work Placements Accident Report, Postsecondary Student Unpaid Work Placement Workplace Insurance Claim, and Letter of Authorization to Represent Employer forms (please refer to the WSIB Responsibility Matrix on page 2). These three forms can be found on the Faculty’s website at: https://bloomberg.nursing.utoronto.ca/current-students/student-forms#content4. This online form will be used to help track WSIB injuries and to ensure required documentation has been submitted.

We recognize that other types of incidents aside from physical injuries may occur during a clinical placement. For non-WSIB incidents (e.g., medication errors, bullying, etc.), the purpose of collecting this data is to help the Faculty be better informed about some of the challenges our students face while completing their placements. Students, faculty, clinical instructors, and preceptors can provide us with descriptions of these challenges so that students receive appropriate support and follow-up.