Incident Report

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You are currently viewing the Clinician report form. If you are a Consumer, please use the consumer report form to report your incident or compliment by clicking here

Please enter incident details below - mandatory fields are marked with an asterisk (*).

Country*
Please select a country.

How is the organisation funded?*
Identify if the organisation is publicly or privately funded.

On what date did the incident occur? (Please use date picker on right hand side.)*
Please enter the date the incident occurred using the date picker (right hand side).

Date is
Please enter the date time frame.
Please select a value.
Timeband
Please select a time

Whose safety was primarily at risk?
Please enter the person involved.

Which of the following events did the incident involve?
Please enter what was involved in the incident.

 
What was the patient's triage score on presentation?*
Please enter the patient's triage score on presentation (select one only).

Which medical specialty(ies) was involved in the incident?

What was the patient's age at the time of the incident?
Please enter the age of the subject.

Gender
Please enter the gender.

Clinical presentation
Please enter a clinical presentation.

 
What happened?*
Please enter the details of the incident. This includes what happened, who was involved and how the situation was dealt with immediately after it occurred. Please use generic descriptions - Nurse A- Doctor on duty etc.

What were the contributing factors?
Please enter details of factors which contributed to the incident occurring. For example, insufficient staff, patient intoxication, failure to read etc

What were the factors that reduced the impact of the incident?
Please enter the factors that reduced the impact of the incident.

What were the consequences or outcomes of the incident?
Please enter the consequence or outcome details.

How could the incident have been prevented?
Please enter how could the incident have been prevented.

 
What was the immediate action(s) taken to manage the incident?
Please enter the immediate action taken.

What is your designation?*
Please enter the notifier designation.

At what stage of the patient's journey was the incident first initiated?*
Please enter how the incident initiated.

At what stage of the patient's journey was the incident detected?*
Please enter how the incident was detected.

Did this incident or near miss involve a failure associated with application of the correct patient, correct site or correct procedure policy?
Please enter a value.

Did the incident involve a problem with handover?
Was it a communication or handover failure?

Is this incident a 'burst report' on either of the following incident types?
Is this incident a 'burst report' on either of the following incident types?

Enter the correct numbers into the box below
Enter the correct numbers into the box belowPlease enter the correct numbers

When you click 'Submit' it may take a second or two to load this incident into the database