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TESTING ONLY

The CEPCP Patient Safety & Learning Self-Report form is currently availble for testing only. Please continue to contact the CEPCP to report issues.

CEPCP Patient Safety & Learning Self-Report

This self-report supports learning, patient safety, and system improvement.
Near-misses and “good catches” are valuable to report.

Paramedics are always welcome to call and speak directly with a Base Hospital coordinator if they would prefer to discuss a clinical situation or patient safety concern.

Base Hospital Office: (905) 433-4370
Office Hours: 07:00–15:30

Calling the Base Hospital is always an option. This self-reporting form is intended to make patient safety reporting easier and more accessible, not to replace direct clinical support or discussion.

Please do not include patient identifiers or PHIPA related information.

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Please enter the date of the call

Provide the clinical and situational context of the call, including the patient presentation, relevant assessment findings, and any factors that influenced clinical decision-making. Clearly describe the event you are self-reporting and the circumstances surrounding it.

Please include, where applicable:

  • The context of the call and presenting complaint
  • Pertinent patient history and assessment findings
  • Clinical signs, symptoms, and monitoring data relevant to care
  • Environmental or scene factors that influenced assessment or management
  • Operational or system factors that may have contributed to the event
  • A clear, factual description of the event being self-reported

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Medication Involvement

Was a medication involved?(*)
Was a medication involved?
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Timing (approximate)
Timing (approximate)



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Medication-related contributing factors (select all)
Medication-related contributing factors (select all)








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What helped reduce harm or catch it? (Select all that apply)
What helped reduce harm or catch it? (Select all that apply)




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Contributing Factors

The following factors help us understand the conditions surrounding the event.
Please select any that contributed.

(Select all that apply)

Patient Factors
Focuses on the clinical presentation and the patient's physical/behavioral state.
Patient Factors


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Provider & Clinical Performance
Focuses on the individual clinician's knowledge, state of mind, and execution.
Provider & Clinical Performance





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Team & Communication
Focuses on the dynamics between people and the chain of command.
Team & Communication

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Systems, Equipment & Environment
Focuses on the "tools and rules" and the physical surroundings.
Systems, Equipment & Environment



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Safety Ideas

Anything you would do differently next time
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Changes that could make this easier or safer next time
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Mandatory Self-Reflection

This section is required to support your ongoing learning and professional growth. Please note that responses are used for development purposes only and are not part of any disciplinary or performance management process.

  • Strategies: Which strategies were effective, and which could be applied to similar situations in the future?

  • Course Correction: Were there specific moments where a pause, double-check, or a different approach might have changed the outcome?

  • Early Detection: What environmental factors or conditions would you want to recognize sooner next time?

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Please provide your thoughts

Follow-Up Preference

Would you like follow-up from CEPCP
Would you like follow-up from CEPCP
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