Patient Safety Incident report form – Northern Ireland
This form is to be used to record details of medication safety incidents that are related to errors and near misses that occur within the pharmacy. It should not be sent to HSCB. This form does not count as formal notification of a dispensing error to the NPA as your indemnity provider; this should be done separately by telephone if appropriate. Patient information should be anonymised in this electronic form.
Pharmacy/Branch name
NPA membership number
Date report completed *
MM
/
DD
/
YYYY
Date of incident *
MM
/
DD
/
YYYY
Description of medication incident
Describe what happened:
(Give as much detail as necessary to enable others to understand the circumstances and be able to learn from the event; state facts only not opinions).
Do not disclose patients details, code names can be used for patients e.g. 'patient A' or 'Mrs B'
Describe what happened:
Describe any actions planned or taken to prevent a reccurence:
Were there other important factors? (tick all that apply)
If other or unknown please specify here
Contributing factors: what were the apparent contributing factors? (tick all that apply)
If other or unknown please specify here
In your view, what were the underlying causes or events which, if rectified, may prevent the incident from harming another patient?
At what stage during the medication process did an actual or potential error occur? (tick all that apply)
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