Self-Report Form – Incident Self-Report Name (midwife) Email (midwife) Address (midwife) Phone (midwife) Date of incident Type of sentinel event Maternal mortality Perinatal mortality Maternal shock Uterine rupture Maternal or neonatal seizure NICU or special care nursery admissions within 72 hours of birth (excluding for observation or congenital anomalies Please describe the incident that meets the self-reporting criteria and explain why you think this meets criteria for incident review. Make sure to include the following details, as relevant, to help determine whether this case warrants a full review: maternal age, parity, gestational age, length of various stages of labor, duration of ROM, presence of meconium, GBS status and treatment, FHTs, vital signs, APGARS, method and time of decision to transport, and hospital course/outcome.In the event the QMP determines that this does not warrant an incident review, do you still feel you would benefit from an incident review? If so, what would you hope to gain from an incident review and what aspects would you like to focus on during the review?Would you like to invite one additional individual, beyond the 2-3 panel members selected, who was present at this incident to participate in this review? If so, please provide the name, role at the birth, and contact information: Share236TweetPinShare236 Shares
