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Quality Assurance Quality Improvement Incident Review Request Form

Case Review Request

 The goal of EMS at the Islip Terrace Fire Department is to provide the community with the very best care. This form was created to provide an opportunity to document concerns about issues that may arise during a run at any phase of out-of-hospital emergency medical care. It was adapted from Suffolk County's EMS INITIAL CASE REVIEW - FIELD REPORT PROCEDURE AND FORM as a way to encourage review and allow the Islip Terrace Fire Department to address and resolve situations internally.

Although you may remain anonymous, it's sometimes necessary to speak with the person requesting the Case Review to obtain more information. Your name and all identifying information will remain completely confidential and will not be disclosed without authorization.

Some reasons for requesting a case review are (but not limited to):

  • Exceptional Care or Recognition of an EMS Provider/Crew
  • Provider Self Reporting
  • Citizen or Patient Complaints
  • Interactions with Crew Members
  • Interactions with Family Members or Other Witnesses On Scene
  • Interactions with Other Agencies, Providers, Hospitals or Medical Control
  • Patient Care inconsistent with established New York State and Suffolk County Protocols
  • Patient Care inconsistent with Department Standard Operating Guidelines related to EMS Operations
  • Deviation from Accepted Medical Practice Standards

You may upload a file that describes the event or type the details in the area provided. Please provide as much information and be as thorough as possible. If you provide your name, you will be provided with status updates and informed of outcomes.


 

Date Of Incident
Run # (if known)
Incident Address/Location
Name(s) of Individuals Involved (if known)
If you have a file containing a description of the incident you may upload it (Maximum 120mb)
Description (if not uploading a file)

 It may be necessary for us to contact you in order to obtain more information during our investigation. Your personal information will be kept completely confidential and will not be shared with anyone outside of the Quality Assurance Continuous Quality Improvement (QAQI) Committee without your consent.

You may chose to remain anonymous, but please understand that we may not have enough information to fully investigate the incident. We will also be unable to provide you with status.

 

First Name
Last Name
Email Address
Phone
 I prefer to remain anonymous
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