Hemovigilance Module Incident - NHSN

Form Template

If the facility chooses “detailed reporting of all incidents” on the monthly reporting plan, a Hemovigilance Module Incident form must be completed for every incident that occurs.

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Report only one incident per form. Near misses and approved deviations should be documented as robustly as incidents associated with patient reactions. All reports should be entered within 30 days of the month of the “Date incident occurred” for the event. If the summary reporting option is chosen on the monthly reporting plan, the Hemovigilance Module Incident form should be completed for all high-priority incidents, all incidents that are related to an adverse reaction, and any additional incident that may warrant collection of detailed information on. These detailed reports should also be documented on the Monthly Incident Summary form.

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