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Incident Report

An Incident Report is to be filled out and submitted to the National College of Midwifery for any clinical experience at which an NCM student was present and which resulted in either a lawsuit or the death of the birthing person/infant. This report must be filled out and emailed to the College at info@midwiferycollege.edu no later than two weeks from the death or the initiation of the lawsuit. Ideally, it should be filed immediate-ly. The executive staff of NCM will review the Incident Report Form upon re-ceipt and will take appropriate actions with regard to each incident. Ap-propriate actions may include but are not limited to: requiring the pre-ceptor to undergo local or national peer review, reviewing the precep-tor’s standards of practice, recommending remedial education, or dis-missing the preceptor from the College faculty. Since the laws regarding the practice of midwifery vary widely from state to state, NCM feels it is best for states to be responsible for determining appropriate action based on the midwife’s adherence to particular guide-lines or standards of care. Therefore, in the context of the College, ap-propriate action will be determined on the basis of NCM’s assessment of ethical conduct. Violation of ethical conduct includes but is not limited to: performing any procedure without informed decision making on the part of the client, failing to inform a client about the legal status of the practice of midwifery in the jurisdiction, falsifying documentation, falsely presenting skill level or experience of the preceptor or student, or any dishonest behavior. Please remember that every conversation you have about this incident is discoverable in a court of law. This reporting procedure is designed to inform NCM how to best sup-port NCM preceptors and students to learn from difficult situations and to ensure that students are receiving an education that is consistent with NCM standards. You will be sent an emailed copy of the report you submit.

General Information

Preceptor's Full Name^*

Students' Full Name^*

Any NCM students who were present at the time of the incident.

NCM Email^*

Phone Number^*

Best number to contact you at. (Please input only numbers.)

Report

This incident is concerning (check all that apply):^*

Death of a baby Death of a birth person Lawsuit

Incident Narrative^*

Please provide a brief description of the incident, what lead to it and the current status.

Describe the informed decision making that was done relative to the in-cident.^*

Please take time to self-reflect and describe any actions you could have taken that would have better brought you into alignment with NCM’s standards of ethical conduct. This includes engaging the client in in-formed decision making, informing the clie^*

The Board of Directors will review Incident Report Forms upon receipt, and will take appropriate actions in regard to each incident. Appropriate actions may include, but are not limited to: requiring the preceptor to undergo local or national peer review; reviewing her standards of practice; recommending remedial education, or dismissing the preceptor from the College faculty. Dismissal will only be considered in cases in which the preceptor failed to follow the guidelines of practice in her State, or the guidelines of the New Mexico Midwives Association, whichever are more conservative.

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Incident Report

General Information

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