60.0F Phlebotomy Incident Management
Investigation form


Title of Manual: Specimen Collection

Version No: 1.0

Title: Phlebotomy Incident Management Investigation Form

Effective Date: 12/20/10
Revised Date: 06/23/14

Document #: GPA.SPC.60.0F



Date & Time of Incident:

Patient Name:

Location where incident occurred:

Incident Reported by:


Describe What
Occurred:_______________________________________________________________________________
Immediate Action Taken:__________________________________________________________________________________ Who Was
Involved:________________________________________________________________________________
What Procedure (s) Were Involved:________________________________________________________________________________
Was Patient’s Physician Notified:________________________________________________________________________________
Name of
Physician:_______________________________________________________________________________
Who did you notify at
GPA:___________________________________________________________________________________
What was the outcome:________________________________________________________________________________

Signature:___________________________________________
Date:_______________________________________________

Original to: Phlebotomy Supervisor/Laboratory Manager
Copy to: Director of Human Resources

X. DOCUMENT HISTORY

X - MINOR REVISION
(Laboratory Director’s Signature on Original Subsequent Document Attached)

MAJOR REVISION
(Requires Laboratory Director & Department Director Signature - where applicable)

Reason for Change

2/11/14 New Document Control Format

6/23/14 Moved procedure to
Specimen Collection Manual



Laboratory Director

(Signature)

Date

Natalie Depcik-Smith, MD
(Print)



Department Director

(Signature)

Date

Robert M. Gay, M.D.
(Print)



Designee

Date

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)

(Print)

(Signature)



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