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EMS Near-miss Event Report
EMS Near Miss Event: An unplanned event that did not result in injury, illness, or damage to an EMS practitioner, vehicle, aircraft, or equipment, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage. A near miss event that is patient related should be reported as a "Patient Safety Event".
Date *
MM
/
DD
/
YYYY
Your name (optional)
Your answer
Your agency *
Your EMS certification level *
Your role *
Visibility at the time of event *
Type of transport event *
Agency involvement (select all that apply) *
Required
Phase the event occurred in *
Event Description *
Your answer
What prevented injury, illness or damage in this event? *
Your answer
Did the event occur immediately following other employment or additional shifts?
Estimated number of hours on shift at time of incident *
Contributing factors (choose up to 5) *
Required
What system change may have prevented this event? *
Your answer
Was this event reported to the on-duty Field Supervisor? *
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