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Requestor's IP Address : 18.232.88.17
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Select Incident Type(s)
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Incident Type
Definition
Examples
Adverse Event
Treatment- related incident that may lead to hospitalization or death during the patient course of treatment at the clinic (as per the CPSO definition of Tier 1 and Tier 2 Adverse event)
Patient admitted to hospital within 10 days of an OR procedure
Andrology
Bullying-Employee
NewLife employee or associate gets bullied by another employee of NewLife
Bullying-Patient
Chart documentation
Incident related to documentation in patient chart or in cycles
Missing documentation like an encounter with patient not documented, documenting wrong information or documenting in the wrong chart
Donor Adverse Reaction
DNR AR means the unexpected presence of an infectious disease agent or the unexpected occurrence of an infectious disease in a recipient of sperm or ova or a child created from that sperm or those ova
A report comes after donation showing that the donor was positive for one of the infectious diseases in the donor infectious diseases tests
Donor gametes quarantine
Incident concerning donor gametes quarantine as per the Health Canada Safety regulations
Egg donor who's tests results are not out on the day of retrieval and the donated eggs were not quarantined until the results are out and verified
Donor Program Error
Errors and accidents as described in Health Canada Sperm and Ova Safety Regulation
A donor who did not testing/assessment in compliance with the Health Canada Safety regulations
Donor Sperm - (direct)
Incident related to known sperm donor cycle
donor tests not completed/ incident related to recepient cycle
Donor- egg (direct)
Incident related to known egg donor cycle
Donor evaluation not followed/ Cycle monitoring incident/ Recepient problem
Donor- egg (regular)
Incident related to anonymous egg donor cycle
Egg donor evaluation not completed/ egg donor not following cycle instructions/ Problems with recepients
Donor-Intended Surrogate
Incident related to intended surrogacy
Male same sex couple missed assessment before creating the embryos for the surrogacy process
Embryology
Embryology-harm to embryo
Incidents during the embryo fertilization or thawing that may lead to harm to the embryos
Accidents in the embryology lab that lead to loss of one or more embryos
Equipment Failure
Equipment fail to operate for any reason
An ultrasound machine/lab /OR equipment that fails to operate when turned on or stops working properly due to dysfunction
Harassment- Patient
Harassment-Employee
Health and Safety
Any incident that is within the scope of Health and Safety in the organisation
Needle stick injury
Lost and Found
Manufacturer Recall
When: medication/supplies & consumables /device or any piece of purchase used in the treatment of patient is recalled by the manufacturer for a defect or non-compliance to the standard specifications
A batch of medication is recalled because the actual dose is less than what is written on the box
Medical Devices and Equipment
Any incident that is associated with or caused by medical equipment used in Newlife Fertility Centre whether it involves patient care directly or indirectly
Scheduled preventative maintenance was not done in time
Medication Error
Near-Miss
The incident is prevented before harm happens or an error is caught before reaching the patient
Patient identification mix-up is caught and corrected by choosing the right patient
No show-employee
No show-pat
Nursing
Patient complaint
Patient ID
Failure of identifying the right patient
When not using double identifiers to select the patient's chart, the documentation and treatment will go to another patient *Major Patient Safety Hazard*
Patient Privacy/ confidentiality
Incident related to patient privacy or confedentiality of their health information
Patient information is shared with unauthorized party without permission, patient privacy is not followed during a visit to the clinic
Patient Safety
Any incident that may have an impact on patient safety
improper Patient identification
Payment not collected
PGTA
Any error related to PGT-A test
PGTA result
Phlebotomy
Physical Damage
Protocol not followed
Reception
Shipping/Receiving embryos or gametes
Incident related to shipping embryos or gametes from and to NewLife laboratory
Shipment arrived without lab approval, shipment arrived without notice, missing documents for a shippment, accident during shipment or requirement not fulfilled
Storage/embryos and gametes
Incident related to cryopreservation of embryos or gametes
Storage fees not paid, discard or donation requests not fulfilled, Storage ID or information incorrect
Theft
Wrong billing
Wrong Booking
Patient booked for wrong type of appointment
Wrong reporting
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Person Type
Definition
Individual
If you are reporting this for yourself.
Business
If you are responsible for reporting this for your employer or your own business.
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Person Type:
CONTRACTOR
DOCTOR
EMPLOYEE
MANAGER/SUPERVISOR
PATIENT
REPORTING PERSON
WITNESS
Employee ID:
First Name:
Middle Name:
Last Name:
Home Address:
City
 /
State
 /
Zip Code:
 /
Country
 ,
 ,
,
Home Phone:
Mobile Phone:
Email Address:
Email report to this address
Confirm Email:
Employer Name:
Work Address:
City
 /
State
 /
Zip Code:
/
Country
 ,
 ,
,
Work Phone:
Race:
ASIAN
BLACK
HISPANIC
N/A
OTHER
WHITE
Sex:
FEMALE
MALE
OTHER
DOB:
Driver License Number:
Licensing State:
Person Type
Name
Home Phone
Mobile Phone
Work Phone
Enter Involved Contact Information
Please enter your information as completely as possible. You may be contacted regarding this incident. An email address is required if you would like to be notified when this report is received and approved.
Person Type:
CONTRACTOR
DOCTOR
EMPLOYEE
MANAGER/SUPERVISOR
PATIENT
REPORTING PERSON
WITNESS
Employee ID:
First Name:
Middle Name:
Last Name:
Home Address:
City
 /
State
 /
Zip Code:
/
Country
 ,
 ,
,
Home Phone:
Mobile Phone:
Email Address:
  
Email report to this address
Confirm Email:
Race:
ASIAN
BLACK
HISPANIC
N/A
OTHER
WHITE
Sex:
FEMALE
MALE
OTHER
DOB:
Driver License Number:
Licensing State:
Person Type
Name
Home Phone
Mobile Phone
Work Phone
Enter Incident Information
Please enter all the information that applies. If you do not know the address of the incident, use the nearest intersection such as Market St./ 10th St. Please ignore previous instructions. LB
Street Address:
City
 /
State
 /
Zip Code:
/
Country
 ,
 ,
,
Incident Time (start):
Incident Time (end):
Have Vehicle Info to Enter?:
Yes
No
Have Property Info to Enter?:
Yes
No
Have Digital Media to Enter?:
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No
Origin of Threat:
Incident Description:
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Enter Vehicle Information
Please enter the Vehicle information.
Type:
2 DOOR VEHICLE
4 DOOR VEHICLE
Make:
ACURA
AUDI
BMW
BUICK
CADILLAC
CHEVROLET
DODGE
FIAT
FORD
GMC
HARLEY DAVIDSON
HONDA
HUMMER
HYUNDAI
INFINITI
ISUZU
JAGUAR
JEEP
KAWASAKI
KIA
LEXUS
LINCOLN
MERCEDES BENZ
MITSUBISHI
NISSAN
OLDSMOBILE
PLYMOUTH
PONTIAC
PORSCHE
RANGE ROVER
SAAB
SATURN
SCION
SUBARU
SUZUKI
TOYOTA
TRIUMPH
VOLKSWAGEN
VOLVO
YAMAHA
Model:
Year (YYYY) :
Color:
BLACK
RED
License Plate Type:
AUTOMOBILE
FARM VEHICLE
MOTORCYCLE
PASSENGER
SEMI-TRUCK
TRUCK
License Plate Number:
(do not enter spaces)
Licensing State:
VIN:
(do not enter spaces)
Insurance Company Name:
Insurance Policy #:
Insurance Policy Expiration Date:
Enter Property Information
Please enter the Property information.
OwnerShip:
COMPANY
PERSONAL
Type:
CLOTHING
COMPUTER/LAPTOP
ELECTRONIC DEVICE
EQUIPMENT
FURNITURE
JEWELRY
MEDICATION
MONEY
PURSE/WALLET
STATIONARY/OFFICE SUPPLIES
Subtype:
Brand:
Model:
Color:
BLACK
BLUE
GREEN
GREY
METAL
ORANGE
PINK
RED
WHITE
YELLOW
Serial Number:
How Many:
Approx. Market Value ($):
Property Description:
Select Digital Media
Please select any digital media (pictures, documents or any digital data files) up to 2047 MB that are relevant to this incident.
File Name
Title
Description
Review Report
Please review the report. If all the information is correct, click the Continue button to submit the report. If you need to modify some information, click the desired modify link. This will be your last chance to change information for this report.
General Information:
Incident Type(s):
Reporting Person/Involved Contact Information:
Incident Information:
Incident Location:
Incident Time (start):
Incident Time (end):
Origin of Threat:
Incident Description:
Vehicle Information:
Type:
Make:
Model:
Year (YYYY):
Color:
License Plate Type:
License Plate Number:
Licensing State:
VIN:
Insurance Company Name:
Insurance Policy #:
Insurance Policy Expiration Date:
Property Information:
OwnerShip:
Type:
Subtype:
Brand:
Model:
Color:
Serial Number:
How Many:
Market Value($):
Property Description:
Digital Media:
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