‫بسم ا الرحنم الرحي‬

Accident / Incident Report

Employed information

Full Name: Mohammad foqha

Home Address: Tulkarem Home phone: 0599888823

Circle: Employee (Full-time, part-time, perm., temp.)

Job Title: Registered Nurse Supervisor: Mr. Basil Abu Khadra

Information about the incidence:

Name: Mohammad farook Age: 65 years old address: Tulkarem

Sex: Male
Diagnosis: CVA (cerebra vascular accident )
Status: Inpatient.
Date &Time of Occurrence: 11:00 A.M, in 29/10/2014
Occurrence Location: Thabet Thabet Hospital in Tulkarem
Report Date & Time: 11:30 am in 29/10/2014.

Describe briefly The Occurrence:

Surgical department in 29/10/2014 at 11:00 am . When I am at the counter that I have
a recordV/S of cases , one of patients in room 15 tell me that the patient in room 15
bed 1 called Mohammad farook, falling down during walking, lead to head injury and
pain in the right hand, I left all my work , then I went to reassure on patient, I saw the
patient on the ground, semi conscious, with bleeding on front on his head ,then I put
patient in the comfortable position and I stopped the bleeding, and I told the head
nurse(Mr. Basil Abu Khadra) face to face at 11.00 am and I mentoring the patient for
any complication, the bleeding stop after 1 mint , The doctor Sami Herzall informed
by telephone at 11.05 am about pt health status as incident(Falling down , pt semi
consuse ,with head injury and pain on his Rt hand(that what I told to the doctor sami
) )to evaluate the status of the patient , doctor Sami told me to take a vital singe and
monitoring for any complication , till he come to him after 5 minutes. All of my
actions were documented in patient file at 11.07 minutes .

Physician Notified: Yes

Name: Sami Herzall Date: 29/10/2014 Time: 11.00
am
Seen by Doctor: Sami Herzall Date: 29/10/2014 Time: 11.10am.

X-rays Taken: Yes

CT scan: Not taken .because no CT in Thabet Thabet hospital .

Physicians Comments:
The doctor come to assess the status then decided to work x ray after that to sure if
there any problem in patient head and to work cast for a broken in the right hand.

Action Taken (Continue on a separate sheet if necessary):

Monitor V/S, level of conscious, IV fluids, sign and symptom of edema and evaluate
sensation and I assist the doctor in the work of cast.

Completed By: Mohammed Mansur . Date: 29/10/2014

Clinical Nurse Manager or Dept. Manager: Mr. Basil Abu Khadra Date:
29/10/2014

Administration Route:
1- keflex: 1g q 6 hr by IM administration Date: 29/10/2014

2- Dextrose saline 5%: IV administration Date: 29/10/2014

3- Morphine: 100-150mcg/kg, as require by IM administration as a doctor order

Date: 29/10/2014

Witness 1: kareem atili

Witness 2: Omar shehade

Witness 3: Nareen farek

Date Report Completed:29-10-2014 at 11.30 am.