DCIQ: South East London ICS Incident Reporting Form

South East London ICS Incident Reporting Form

1. Details
2. - Are you reporting a patient safety event?
    You must enter a value in this field
  - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Incident time (hh:mm)
    You must enter a value in this field
  - Description
    Enter facts, not opinions. Do not enter names of people
    You must enter a value in this field
  - Action taken
    Enter action taken at the time of the incident
    You must enter a value in this field
  - LFPSE - (Staff) How did staff availability affect the event?
    You must enter a value in this field
  - LFPSE - Clinical Outcome
    You must enter a value in this field
  - LFPSE - How was medication involved in what went wrong?
    You must enter a value in this field
  - LFPSE - Name of Medication involved in what went wrong
    You must enter a value in this field
  - LFPSE - Patient Age
    You must enter a value in this field
  - LFPSE - Patient Physical Harm
    You must enter a value in this field
  - LFPSE - Patient Psychological Harm
    You must enter a value in this field
  - LFPSE - Was the availability of staff a factor in this incident?
    You must enter a value in this field
  - LFPSE - Which of the following medication processes were involved in what went wrong?
    You must enter a value in this field
1. LFPSE
1. LFPSE - Risk
1. LFPSE - Went Well
1. LFPSE - Medications
1. LFPSE - Equipment
1. LFPSE - IT Systems & Software
1. LFPSE - Tissues & Organs
1. LFPSE - Involved Persons
1. LFPSE - Reporter
1. LFPSE - Adverse Event Agent
1. LFPSE - Adverse Event Problem Buildings Infrastructure
1. LFPSE - Adverse Event Problem Estates Services
1. LFPSE - Adverse Event Problem Blood
1. LFPSE - Adverse Event Problem Blood Products
1. LFPSE - Adverse Event Safety Challenges
1. Type of Record
2. - Type
    You must enter a value in this field
  - Clinical or Non-clinical?
    You must enter a value in this field
    Clinical
    Non-clinical
  - LFPSE Reference / StEIS Number / or other Reference Number
    You must enter a value in this field
  - Never Event
    You must enter a value in this field
1. Services
2. - Primary Service
    You must enter a value in this field
1. Quality Alert Details
1. Incident Coding
2. - Incident affecting
    You must enter a value in this field
  - Category
    You must enter a value in this field
  - Sub category
    You must enter a value in this field
  - Tick to record person affected contact details
    You must enter a value in this field
  - Patient's / Service user's NHS number
    If applicable
    You must enter a value in this field
1. Medications
1. Equipment
1. People Affected
1. Result & Severity
1. Notifications
1. Additional Information
2. - Was any employee directly involved in this incident?
    You must enter a value in this field
  - Was any other contact involved in this incident?
    You must enter a value in this field
  - Are there any documents to be attached to this record?
    You must enter a value in this field
1. Employees
1. Other Contacts
1. Documents

Incidents

South East London ICS Incident Reporting Form