FORM IR1

PATIENT SAFETY INCIDENT - MANAGEMENT & REPORTING FORM

PART I – Initial Report
A. Incident particulars (refer to guidance notes for sentinel event and incident codes)

If Sentinel Event, enter code from Box 1 Enter Incident Code from Box 2 ‘Near Miss’? Yes No

24 hour clock
D D M M Y Y H H M M D D M M Y Y
Date of incident Time of Incident Date ofreporting

Unit/Dept. Ward/Clinic

Specialties involved

B. Patient particulars

Name Male Female Inpatient Outpatient

D D M M Y Y

ID/Passport No. Date of birth

D D M M Y Y
Date of admission Diagnosis

Race Communication problem with patient? Yes No

Native language Language used to communicate

C. Incident description

Provide a brief description of the incident, the people involved (including staff), any harm suffered by patient and any immediate staff response. Please
state facts and not opinion.

Full name
Designation

Continue on separate sheet if necessary.

PART II – Immediate Supervisor Report(e.g. specialist, consultant, ward manager, matron, etc.)

D. Immediate corrective action taken to reduce risk

Provide a brief description of any corrective action taken immediately following the event.

Full name
Designation Date

Continue on separate
Official Use Only: Date received _____________ Incident Reference __________________
 Part III – Designated Person Report(Full name _________________________________ Date__________)
E. Investigation priority assessment (triage) and response (refer to guidance)

1. Actual patient impact/outcome (circle appropriate box/letter: H=High, M=Medium, L=Low) 4. Circle the A P Response
Negligible Minor Moderate Major Death A(ctual H H Full RCA
L M M H H impact) and H M Mini RCA*
P(otential H L Mini RCA*
risk) boxes. M H Mini RCA
2. Duration of impact Temp. Permanent N/A Unsure
M M Mini RCA
* A full RCA M L Minimal
3. Potential risk to future patients and organisation if no further action taken (circle box/letter) may be L H Mini RCA
1. Most likely Impact/Outcome required for
L M Minimal
2. Likelihood Negligible Minor Moderat Major Death accountabilit
L L None
e y purposes.
Almost certain L M M H H
Likely L M M H H 5. Investigation response
Possible L M M M M Suggested Actual
Unlikely L L M M M None
Remote L L L L L Minimal
Mini RCA
Full RCA

F. Contributing factors (write,select codes from list or attach a copy of RCA reportor fishbone diagram)

1 Patient
2 Task and technology
3 Individual staff

4 Team

5 Work and care environment

6 Management and organisational

7 External

G. Further action proposed to reduce risk (write or attach a copy of RCA report or action plan)
Date action
No Description Person responsible
completed
1

PART IV – Head of Department Comments

I. Organisational impact/outcomes, learning points and general comments

Full name

Designation Date

Continue on a separate sheet if necessary.