Near Miss Date *
Near Miss Date
Near Miss Approximate Time *
Near Miss Approximate Time
Visibility at the Time of the Event *
Your Role in Event *
Contributing Factos *
If the system change was implemented, how many weeks were there between the time you identified the change until it was implemented?
Describe the lessons learned as a result of the Near Miss Event. (What lessons were learned? What are your suggestions to prevent a similar event? What actions can correct the situation? ) Identifying department indicators that may identify you or your department will not be included in reports. Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision Making, Equipment, Incident Command, Role, Sleep Patterns, Situational Awareness, SOP/SOG, Staffing, Task Allocation, Teamwork, Training, Weather.
Did the Event Occur Immediately Following Other Employment or Additional Shifts? *
Number of Staffed Units Operating at the Time of the Event *
How many staffed units where scheduled on the road during the time of the event. Disregard how many units were active or engaged on calls.

Sentinel Event Date *
Sentinel Event Date
Sentinel Event Approximate Time *
Sentinel Event Approximate Time
Your Role in Event *
Contributing Factors *
Sentinel Events are patient safety events which result in Death, Permanent Harm, or Severe Temporary Harm requiring intervention to sustain life. Please describe the event, the actions leading up to it, and any known outcomes.
If the system change was implemented, how many weeks were there between the time you identified the change until it was implemented?
Describe the lessons learned as a result of the Sentinel Event. (What lessons were learned? What are your suggestions to prevent a similar event? What actions can correct the situation?) Identifying department indicators that may identify you or your department will not be included in reports. Keep in mind the following topics when preparing your narrative: Chain of events, Communication, Decision Making, Equipment, Incident Command, Role, Sleep Patterns, Situational Awareness, SOP/SOG, Staffing, Task Allocation, Teamwork, Training, Weather.
Did the Event Occur Immediately Following Other Employment or Additional Shifts? *
Number of Staffed Units Operating at the Time of the Event *