# ASC incident report template > A one-to-two page incident report for surgery centers. It records the patient, procedure, phase of care and harm level. It also logs who was told and when, plus a first review that feeds QAPI. Staff fill in the facts during the shift. The manager decides how deep to investigate. Source: https://incidentkit.ai/templates/asc-incident-report · Updated Oct 5, 2026 ## When to use it - A patient is hurt, or nearly hurt, before, during or after a procedure: a fall, burn or drug event. - A surgical safety event: wrong site, side, patient, procedure or implant, a retained item, or a count that does not match. - A patient is sent to a hospital, or admitted, unexpectedly after the procedure. - Equipment fails while in use on a patient, including events that may need an FDA report. - A near miss: an error caught at the time-out, count or scan, before it reached the patient. ## The template ### 1. Event details - Facility and location (Room or area, such as OR 2, PACU bay 4 or pre-op.) - Date of event - Time of event (Your best guess is fine. Say so in the story.) - Time the event was found (Leave blank if the same. A count error found in recovery is later.) - Event type (Pick the closest fit. Add detail in the story.): Fall / Burn or fire / Medication event / Wrong site, side, patient, procedure or implant / Retained item or count mismatch / Positioning or pressure injury / Equipment or device event / Unplanned transfer or admission / Infection concern / Anesthesia or airway event / Specimen event / Behavior or security / Other - Reported by (name and role) ### 2. Patient and procedure - Patient name or medical record number (Use only what policy allows. Treat this page like a chart.) - Patient date of birth - Scheduled procedure - Procedure done, if different - Proceduralist and anesthesia provider (Names or roles, per policy. The review looks at the system.) - Anesthesia type: None or local only / Moderate sedation or MAC / Regional or neuraxial / General / Not applicable - ASA physical status: I / II / III / IV / Not recorded ### 3. Where in the case it happened - Phase of care: Scheduling or pre-arrival / Registration and pre-op / Time-out and prep / Procedure / Emergence from anesthesia / PACU or phase II recovery / Discharge / After discharge (call-back or return) / Non-patient area - Time-out done before the procedure?: Yes / No / Not applicable - Counts (sponge, sharps, instruments) matched at close? (If off, record who was told, how it was settled, and any imaging.): Yes / No: see story / Not applicable - Equipment or device involved (Name, model, serial or lot number. Tag it and pull it from use.) - Medication, implant or specimen involved - Did the event reach the patient? (Report near misses too. They show a safeguard that worked.): Yes / No: caught before it reached the patient (near miss) ### 4. What happened - Description of the event (What you saw and did, in order. Facts only, no blame.) - Immediate actions taken (Care given, equipment secured, procedure stopped or finished, who was called.) - Patient condition after the event (Vital signs, symptoms, exam findings and any change from before.) - Witnesses and others present (Name and role. Collect written statements apart from this form.) ### 5. Outcome and harm - Harm level (Use your harm scale, such as AHRQ Common Formats. Re-rate if the patient changes.): No harm / Mild harm / Moderate harm / Severe harm / Death - Additional care needed: None / Extra monitoring only / Treatment in the ASC / Delayed discharge / Unplanned transfer to a hospital / Unplanned hospital admission after discharge / Repeat or corrective procedure - Receiving hospital and transfer time (Record call time, handoff and who accepted. CMS expects ASCs to track every transfer.) - Possible sentinel or serious reportable event (If yes, tell the administrator and risk lead now. Start a root cause analysis. Check state rules.) - Possible device-related death or serious injury (ASCs are device user facilities. Report deaths to the FDA and maker, and serious injuries to the maker, in 10 work days (21 CFR 803.30).) ### 6. Notifications - Administrator or medical director told (name, date, time) - Surgeon or attending physician told (name, time) - Patient or representative informed (who, by whom, date, time) (Write what was said and how the patient responded. Follow your disclosure policy.) - Risk manager or quality lead told (name, date, time) - External reports made (state, accreditor, insurer, FDA) (Write 'none' if none. Deadlines differ by state: check yours.) ### 7. Initial review (manager) - Conditions seen that may have helped cause it (List conditions, not people: staffing, schedule pressure, equipment, labeling, handoff, layout.) - Preventable?: Likely yes / Maybe / No / Not sure: needs investigation - Investigation level: Manager review / Focused investigation / Full root cause analysis - Investigation owner and due date - Added to the QAPI event log ### 8. Sign-off - Completed by (name and title) - Signature of person completing the report - Manager or administrator review - Date reviewed ## How to fill it out well 1. Finish sections 1 to 4 before the shift ends. The manager completes sections 5 to 7. 2. Write what you saw: times, what was said, what equipment was in use. Skip guesses about why. 3. Record time-out and count status even when normal. They show which safeguards ran. 4. Secure the equipment, implants, vials and packaging. Tag any device and keep it out of use. 5. Chart clinical facts in the medical record. Keep this report separate. Ask counsel how your state treats incident reports. 6. Send it to the risk or quality lead within your policy window. Set the investigation level that day. ## Tips - Report near misses too. CMS expects ASCs to find errors caught before harm, since they signal future events. - Track every hospital transfer. CMS calls a single transfer a serious, unplanned outcome worth review. - Count events by phase of care each quarter. A cluster shows a weak safeguard. - Write conditions, not people. 'Count not matched before closing' says more than a name. ## Frequently asked questions ### What is an incident report in a surgery center? A same-day, factual record of an event that harmed or could have harmed a patient, visitor or staff member. It starts a review and feeds QAPI. Clinical facts stay in the medical record. ### Does CMS require ambulatory surgery centers to track incidents? In effect, yes. 42 CFR 416.43 requires an ASC to track adverse patient events, study causes and make improvements last. CMS says to at least track hospital transfers. Accreditors like AAAHC review these programs too. ### Which events does CMS give as examples of ASC safety indicators? CMS Appendix L lists patient burn, hospital transfer or admission, patient fall, wrong site, side, patient, procedure or implant, and timely prophylactic antibiotics. Centers may add other measures, and should add infection control. ### Do surgery centers report device problems to the FDA? Yes. Surgery centers are 'device user facilities' (21 CFR 803.3). Report device-related deaths to the FDA and the maker, and serious injuries to the maker (or the FDA if unknown), within 10 work days. ### How does this template work in IncidentKit? Staff describe the event by text. Lauren asks follow-up questions and drafts the fields, marked 'Lauren · draft' until a person reviews, edits and signs. The [surgery center pack](https://incidentkit.ai/solutions/ambulatory-surgery-centers) sets forms, routing and QAPI summaries. ## Sources - [eCFR: 42 CFR 416.43, Quality assessment and performance improvement (ASC)](https://www.ecfr.gov/current/title-42/section-416.43) - [CMS State Operations Manual, Appendix L: Guidance for Surveyors, Ambulatory Surgical Centers](https://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_l_ambulatory.pdf) - [eCFR: 21 CFR 803.30, Individual adverse event reports: user facilities](https://www.ecfr.gov/current/title-21/section-803.30) - [AHRQ PSNet: Reliability of AHRQ Common Format Harm Scales in rating patient safety events](https://psnet.ahrq.gov/issue/reliability-ahrq-common-format-harm-scales-rating-patient-safety-events) - [AAAHC: Accreditation](https://www.aaahc.org/accreditation/) ## Related - [Incident reporting software for surgery centers](https://incidentkit.ai/solutions/ambulatory-surgery-centers) - [ASC QAPI requirements: 42 CFR 416.43 explained](https://incidentkit.ai/compliance/cms-qapi/ambulatory-surgery-centers) - [AAAHC accreditation: surveys, deemed status and QI studies](https://incidentkit.ai/compliance/accreditation/aaahc) - [Medical device reporting for user facilities: 21 CFR 803](https://incidentkit.ai/compliance/reporting-deadlines/device-adverse-event-reporting) - [Replace Paper Incident Forms: A Practical Switch Plan](https://incidentkit.ai/use-cases/replace-paper-incident-forms) - [Root Cause Analysis Worksheet (5 Whys Template)](https://incidentkit.ai/templates/root-cause-analysis-worksheet)