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Completed by
Date of report
Incident or near miss
Serious incident (notify management within 8 hours)
Data breach
NHS number
Any additional patient characteristics to note: mobility, condition, etc.
Date and time of the incident
Month
Month
Day
Year
Time
:
Hours
Minutes
AM
Location of the incident
Staff / people involved
Category
Patient safety incident or near miss
Health & safety / staff / needlestick injury
Serious incident
Other
Description of the incident
Were there any adverse consequences for the patient? If so, what were they?
Were there any adverse consequences for the staff member? If so, what were they?
Cause(s) of the incident
Incorrect assessment of urgency
Wrong medication or device
Wrong treatment
Incorrect protocol
Incorrect use of protocol
Faulty or missing equipment
Time pressure / high workload
Lack of attention
Lack of competence or training
Patient-related cause
Other
Further details
Has the patient made a complaint?
Yes
No
Not (yet) known
Has the incident been discussed with the patient and/or their family?
Yes
No
If yes, when?
If no, why not?
Assessment of the incident: likelihood of recurrence
Weekly
Monthly
Annually
Less than once a year
Severity of the incident
Catastrophic
Major
Moderate
Minor
Has the incident been reported to the CQC?
Yes
No
If yes, to which body, when and by whom?
If no, why not?
Recorded in improvement log under no.
Surname
Submit
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