Type 2 Occurrence Report

Type 2 occurrences are to be reported to the College annually by the designated Registrant. Type 2 occurrences as defined in the General Regulation are:

  • Any infection occurring in a patient in the premises after a procedure was performed at the premises.
  • An unscheduled treatment of a patient by a Registrant occurring within five days after a procedure was performed at the premises.
  • Any adverse drug reaction occurring in a patient after a procedure was performed at the premises.


An adverse drug reaction is defined as a harmful and unintended response by a patient to a drug or substance or combination of drugs or substances that occurs at doses normally used or tested in humans for the diagnosis, treatment or prevention of a disease or the modifications of organic function.

PART 1: PREMISES INFORMATION

Please provide the following information about the premises (clinic) where the occurrence happened.

Please enter the name of the clinic (the registered IVIT Premises) at which the occurrence happened.

Please enter the number and street name where the clinic (the registered IVIT Premises) is located.

Please enter the City in which the clinic (the registered IVIT Premises) is located.

ON
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Please enter the Postal Code of the clinic (the registered IVIT Premises).

To provide context to the overall number of Type 2 occurrences, please indicate the number of IV bags that were compounded on site for the purpose of intravenous infusion therapy between March 2, 2024 and March 1, 2025 (if compounding is not done on site, please enter “0”).

To provide context to the overall number of Type 2 occurrences, please indicate the number of instances where intravenous infusion therapy was administered to patients in this premises between March 2, 2024 and March 1, 2025.



PART 2: DESIGNATED REGISTRANT INFORMATION

Please enter your first name.

Please enter your last (family) name.

Please enter your College Registration number.

Please enter your e-mail address.



PART 3: OCCURRENCE INFORMATION

The following sections will ask for specific information about occurrences in three areas:

A. Infections

B. Unscheduled Treatments

C. Adverse Drug Reactions.


This form is a dynamic form and it will adjust the questions based on your responses in certain areas.

A. Infections

A1 - Infection Occurrences*

During the period of March 2, 2024 to March 1, 2025, were there any instances of an infection that occurred in a patient after receiving IVIT at this premises?

Please indicate the overall number of infections that occurred during this reporting period.To enter the number, you can either use the arrow keys on the right or enter the number manually.

Please select all of the types of infections that have occurred in this Premises. If an infection occurred that is not listed, please select "Other (specify below).

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Bronchitis*

Please indicate whether the bronchitis infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Cystitis*

Please indicate whether the cystitis infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Gastroenteritis Infections*

Please indicate whether the gastroenteritis infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Influenza*

Please indicate whether the influenza infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Pharyngitis*

Please indicate whether the pharyngitis infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Pneumonia*

Please indicate whether the pneumonia infection occurred after an IVIT that was administered through a delegation.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Delegation - Sinusitis*

Please indicate whether the sinusitis infection occurred after an IVIT that was administered through a delegation.

Please specify the "other" types of infections that have occurred and the number of patients who had the infection.

Delegation - Other Infection*

Please indicate whether the "other" types of infections occurred after an IVIT that was administered through a delegation.

Please provide any additional information.


B - Unscheduled Treatments

B1 - Unscheduled Treatments*

During the period of March 2, 2024 to March 1, 2025, were there any instances where an unscheduled treatment of a patient by a Registrant occurred within five days after a procedure was performed at this premises.

Please indicate the number of instances where an unscheduled treatment was required. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Please indicate the unscheduled treatment provided for patient(s) with anxiety.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for anxiety - delegation.*

Please indicate whether the unscheduled treatment for anxiety occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with dizziness.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for dizziness - delegation.*

Please indicate whether the unscheduled treatment for dizziness occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with headache.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Unscheduled treatment for headache - delegation.

Please indicate whether the unscheduled treatment for headache occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with fatigue.

To enter the number, you can either use the arrow keys on the right or enter the number manually.

Unscheduled treatment for fatigue - delegation.*

Please indicate whether the unscheduled treatment for fatigue occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with infusion site extravasation.


To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for insertion site extravasation - delegation.*

Please indicate whether the unscheduled treatment for infusion site extravasation occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with low back strain.


To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for low back strain - delegation.*

Please indicate whether the unscheduled treatment for low back strain occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with muscle spasm.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for muscle spasm - delegation.*

Please indicate whether the unscheduled treatment for muscle spasm occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with pain at the insertion site.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for pain at the insertion site - delegation.*

Please indicate whether the unscheduled treatment for pain at the insertion site occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with phlebitis.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for phlebitis - delegation.*

Please indicate whether the unscheduled treatment for phlebitis occurred after an IVIT that was administered through a delegation.

Please indicate the unscheduled treatment provided for patient(s) with pneumonia.

To enter the number, you can either use the arrow keys on the right or enter the number manually.


Unscheduled treatment for pneumonia - delegation.*

Please indicate whether the unscheduled treatment for pneumonia occurred after an IVIT that was administered through a delegation.

Please indicate the other condition(s) that occurred among your patients after an IVIT procedure along with the treatment you provided for each condition.

For each condition identified above, please indicate the number of patients for whom you provided unscheduled treatements.

Please indicate whether the unscheduled treatment(s) for these condition(s) occurred after an IVIT that was administered through a delegation.

Please provide any additional information.


C - Adverse Drug Reactions

C1-Adverse Drug Reactions*

During the period of March 2, 2024 to March 1, 2025, where there any instances of an adverse drug reaction in a patient after a procedure was performed at this Premises?

Please indicate the number of instances where an adverse drug reaction occurred. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Please select all of the adverse drug reactions that have occurred after an IVIT administration. If an adverse drug reaction that was encountered in your Premises is not included in the list, please select "Other (please specify below).


Please indicate the number of adverse drug reactions following an IVIT administration where anxiety was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - anxiety?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where anxiety was the reaction.

Was a delegation involved in the anxiety related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where diarrhea was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - diarrhea?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where diarrhea was the reaction.

Was a delegation involved in the diarrhea related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where headache was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - headache?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where headache was the reaction.

Was a delegation involved in the headache related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where hypertension was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - hypertension?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where hypertension was the reaction.

Was a delegation involved in the hypertension related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where hypoglycemia was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - hypoglycemia?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where hypoglycemia was the reaction.

Was a delegation involved in the hypoglycemia related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where infusion site extravasation was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - infusion site extravasation?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where infusion site extravasation was the reaction.

Was a delegation involved in the infusion site extravasation related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where maculo-papular rash was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - maculo-papular rash?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where maculo-papular rash was the reaction.

Was a delegation involved in the maculo-papular rash related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where nausea was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - nausea?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where nausea was the reaction.

Was a delegation involved in the nausea related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where phlebitis was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - phlebitis?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where phlebitis was the reaction.

Was a delegation involved in the phlebitis related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where pre-syncope was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - pre-sycope?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where pre-syncope was the reaction.

Was a delegation involved in the pre-syncope related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where seizure was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - seizure?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where seizure was the reaction.

Was a delegation involved in the seizure related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where shortness of breath was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - shortness of breath?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where shortness of breath was the reaction.

Was a delegation involved in the shortness of breath related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where syncope was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - syncope?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where syncope was the reaction.

Was a delegation involved in the syncope related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where urticaria was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - urticaria?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where urticaria was the reaction.

Was a delegation involved in the urticaria related adverse drug reaction*

Please indicate the number of adverse drug reactions following an IVIT administration where vomiting was the reaction. To enter the number, you can either use the arrow keys on the right or enter the number manually.

Severity of adverse drug reaction - vomiting?*

Please indicate the severity of the adverse drug reaction following an IVIT administration where vomiting was the reaction.

Was a delegation involved in the vomiting related adverse drug reaction*

Please specify the nature of the "other" adverse drug reaction(s) as well as the number of each adverse drug reaction(s) following an IVIT administration.

For each adverse drug reaction, please specify its severity using mild, moderate or severe.

For each adverse drug reaction, please specify whether it occurred after a delegation.

Please provide any additional information.



PART 4 - DECLARATION AND SIGNATURE

Declaration*


Do you declare that to the best of your knowledge, the information is true and complete and that you understand that it may be professional misconduct to make a false or misleading statement to the College?

Signature


By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.



PART 5 - Submission Copy

Below is a check box to allow you to receive a copy of your submission. It is strongly recommended that you check this box off and enter your email address. The entries you have made on the form will be emailed to you for your records. This will be helpful in the event that the Inspections Team needs to contact you to clarify any information that you have provided.


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