DCIQ: Datix Cymru Concerns Management System Incident Reporting Form (V4D)***Pharmacy

Datix Cymru Concerns Management System

Incident Reporting Form (V4D)

Pharmacy - Logged Out Form

1. Incident Affecting?
2. - DWEB reference number (if applicable)
    You must enter a value in this field
  - Who was affected?
    You must enter a value in this field
  - Branch Number (if applicable)
    You must enter a value in this field
  - Reference Number
    You must enter a value in this field
1. People Affected
1. When did the incident happen
2. - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Time (hh:mm)
    You must enter a value in this field
  - Reported Date
    You must enter a value in this field
1. Where did the incident happen?
2. - Location of Incident
    You must enter a value in this field
  - Confirm Exact Location?
    Please confirm the exact location
    
    I confirm this is the exact location

Exact location

Incident Severity
- Reporter's initial harm assessment
  This incident is graded on potential harm caused by the Health Body
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please right click over the underlined text and select 'open link in new window.' Grading Framework
  You must enter a value in this field
- Does this incident need external reporting?
  Certain incidents and events are reportable to external agencies, NHS Wales Executive, Welsh Government, Health and Safety Executive (HSE) including RIDDOR, Medicines Healthcare Regulatory Agency (MHRA), Never Events and SMTL.
  You must enter a value in this field
- If the patient took/used the medicine/medical device, what symptoms did they experience?
  You must enter a value in this field
- Manager's interim harm assessment
  This incident is graded on potential harm caused by the Health Body
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please right click over the underlined text and select 'open link in new window.' Grading Framework
  You must enter a value in this field
- Following the initial review, has the grading changed
  You must enter a value in this field
- Please explain why the grading has changed since the record was submitted
  You must enter a value in this field
- Was the healthcare provided a factor or may it have been a factor in a Patient/Service user suffering harm?
  You must enter a value in this field

Incident Details/What Happened
- Description
  Please provide a brief description of the incident ensuring that no identifiable information is included in this box.
  Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP
  You must enter a value in this field
- Brief Description of Actions Taken
  Please provide a brief description of any immediate action taken, ensuring that no identifiable information is included in this box.
  Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP
  You must enter a value in this field
- Vehicle Registration Number
  Where a vehicle was involved in the incident
  You must enter a value in this field
- Booking or CAS Number if applicable (WAST)
  You must enter a value in this field
- Laboratory Specimen Number
  You must enter a value in this field

Incident Type
- Classification
  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
- You have selected 'Other' - Please tell us what Sub Subtype option is missing from the system
  You must enter a value in this field
- Fire Additional Options
  You must enter a value in this field
- Fire alarm activation: Additional Options
  You must enter a value in this field
- Was a ligature used?
  You must enter a value in this field
- Method violence and aggression was received by
  You must enter a value in this field
- Was absconder detained under the Mental Health Act?
  You must enter a value in this field
- Has a Perpetrator been identified?
  You must enter a value in this field
- Please provide as much information that is known about the perpetrator
  e.g. description of perpetrator
  You must enter a value in this field

Perpetrator

Restrictive Practice

Additional Information
- Was any equipment involved in the incident?
  You must enter a value in this field
- Did medication have a direct impact on this incident?
  You must enter a value in this field
- Was a Controlled Drug involved?
  You must enter a value in this field
  - Yes
  - No
  - Don't Know
- Is this Incident related to EPMA (Electronic Prescribing and Medicines Administration)?
  You must enter a value in this field
- Does this Incident have Information Governance considerations?
  The answer should be 'yes' if the incident involves personal or sensitive data, including near misses. For example, a breach of confidentiality, theft, loss or misuse of personal data, information security, etc. For further advice, please contact your information governance team
  You must enter a value in this field
- Does this incident have any safeguarding elements?
  You must enter a value in this field
- if yes, what process(es) were or will be followed?
  You must enter a value in this field
- Is there any factor relating to Emergency Planning for the Incident?
  You must enter a value in this field
- Date of Industrial Action
  You must enter a value in this field
- Further information pertinent to Industrial Action
  You must enter a value in this field
- Is this incident about the nursing care?
  This relates to the NHS Wales Nurse Staffing Act and appropriate staffing level and skill mix
  You must enter a value in this field
- IPC antigens
  You must enter a value in this field
- Were temporary staff involved in the incident?
  You must enter a value in this field
- Was any other contact involved in the incident?
  You must enter a value in this field

Information Governance

Communication
- Is this incident highly confidential (not for circulation)?
  This may include highly confidential information (staff/service user/patient) which requires restricted access. This may include Freedom to Speak up Safely
  You must enter a value in this field
- Who have you informed of the incident?
  You must enter a value in this field
- Please select which 'Other NHS Body' has been informed
  You must enter a value in this field
- Other NHS Body, please provide more detail
  You must enter a value in this field

Medications

When searching for drug ‘administered/omitted’ or ‘intended/suspected’, if you are unable to find the medication involved in the incident please search for ‘other drug’ and select ‘other Drug not listed’. You will then be required to enter details of the medication in the section: Details of ‘other drug’ involved in the incident.

Details of "other drug" involved in the incident
- Please add medication below, if you are unable to find name in medication section
  You must enter a value in this field

Equipment

Blood Transfusion

Violence and Aggression Incidents

Contacts

Openness and Transparency

Duty of Candour (DoC)

Duty of Candour - Initial Notification

Duty of Candour - Written Notification and Investigation Response

Documents
- Are there any documents to be attached to this record?
  You must enter a value in this field

Documents

Yorkshire Contributory Factors Framework

Domain 1: Situational Factors
- Team Factors: Was there any failure or team function?
  For example; Conflicting Team Goals, Poor Delegation, Lack of respect for colleagues, Absence of feedback
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Individual Staff Factors: Were there any reasons this incident was more likely to occur with the particular staff involved?
  For example; fatigue, stress, rushed, distraction, inexperience
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Task characteristics: Did the task features make the incident more likely?
  For example; unfamiliar task, monotonous task, difficult task
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Patient factors: Were there any reasons this incident was more likely to occur to this particular patient?
  For example; Language barrier, unusual physiology, unccooperative, intoxicated, complex medical history
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field

Domain 2: Local Working Conditions
- Workload and staffing issues: Was there a mismatch between workload and staff provision around the time of the incident?
  For example; High unit workload, staff sickness, insufficient staff
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Leadership, Supervision and Roles: Was there any failure of team function?
  For example; inappropriate delegation, remote supervision, unclear responsibilities
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Drugs, Equipment and Supplies: Were there difficulties obtaining the correct drugs and/or working equipment and/or supplies?
  For example, unavailable drugs, inadequate maintenance, equipment not working, no supply delivery
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field

Domain 3: Organisational Factors
- Physical environment: Did the environment hinder your work in any way?
  For example: Poor layout, poor visibility (eg position of nurses' station), lack of space, poor lighting, excessive noise/heat/cold, poor access to patient.
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Support from other departments: Were there any problems from other departments?
  This includes support from IT, HR, porters, estates or clinical services such as radiology, phlebotomy, pharmacy, biochemistry, blood bank, microbiology, physiotherapy, medical or surgical sub-specialities, theatres, GP, ambulances etc
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Scheduling and Bed Management: Did any time or bed pressures play a role in the incident?
  For example: Delay in the provision of care, Difficulties finding a bed, Transfer to an appropriate ward, Lack of out of hours support
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Staff training and Education: Were there any issues with staff skill or knowledge?
  For example: Inadequate training, Training not standardised, No protected time for teaching, No regular/yearly updates
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field

Domain 4: External Factors
- Design of Equipment, Supplies and Drugs: Was there any characteristic about the equipment, disposables or drugs that was unhelpful?
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- National policies: Have any national policies influenced this incident?
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field

Domain 5: Communication and Culture
- Safety culture: Did the lack of safety culture in your clinical area contribute to this incident?
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field
- Verbal and Written communication: Did poor written or verbal communication worsen the situation?
  You must enter a value in this field
  - Yes
  - No
  - Maybe
- Notes
  You must enter a value in this field

Causal Factors Framework Summary
- Which are the most important contributory factors for this incident?
  You must enter a value in this field

Conclusion
- Is this incident related to the five harms of Covid 19?
  You must enter a value in this field
- Post Investigation Harm Assessment
  This incident is graded on potential harm caused by the Health Body
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please right click over the underlined text and select 'open link in new window.' Grading Framework
  You must enter a value in this field
- Result
  You must enter a value in this field
- Lessons learned
  You must enter a value in this field

Details of person reporting the incident

Additional Reporter Details
- Reporters Location
  This would be your usual place of work
  You must enter a value in this field
- Reporters Service
  This would be Service/Dept in which you work/are employed
  You must enter a value in this field

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE

DO NOT DOUBLE CLICK

Incidents

Datix Cymru Concerns Management System

Incident Reporting Form (V4D)

Pharmacy - Logged Out Form

Administered

Intended / Suspected

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE

DO NOT DOUBLE CLICK

Incidents

Datix Cymru Concerns Management System Incident Reporting Form (V4D)***Pharmacy - Logged Out Form***

Administered

Intended / Suspected

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCEDO NOT DOUBLE CLICK

Datix Cymru Concerns Management System

Incident Reporting Form (V4D)

Pharmacy - Logged Out Form

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE

DO NOT DOUBLE CLICK