REPORTING OF ADVERSE INCIDENTS By COMMUNITY PHARMACY SERVICES *Fields 1-5 Not applicable if reporting anonymously Date of Incident: Date Date of Report: 6. 7. 8. Patient Involved? Yes / No Age: Sex: 9. 10. 11. (please delete) Medication Incident? Yes / No 12. (please delete) If Yes please give name (s) of medication involved: 13. Other HSC Organisation Involved? Yes / No 14. (please delete) More details on HSC organisation (if willing to provide them) 15. Brief summary of incident (Should not contain personal detail of patient) 16. Include relevant information regarding the incident eg name, form, dose and quantity of medications prescribed and same for those dispensed (if different), whether the patient actually consumed the medication and any harm that occurred. 16a Please indicate whether this was a miss’ or a dispensing error: ‘near near miss dispensing error other □ □ □ ‘Near miss’ is defined as an incident detected up to and including the point at which the medication was handed over to the patient or patient’s representative. Dispensing error is an incident detected after the patient had taken possession of the medication. 16b Level of harm and likelihood of re-occurrence: See risk analysis table (Appendix 1) for † definitions of these terms If harm occurred please indicate the actual level of harm† caused to the patient by this incident: Insignificant moderate major Catastrophic unknown n/a □ □ □ □ □ □ □
REPORTING OF ADVERSE INCIDENTS By COMMUNITY PHARMACY SERVICES *Fields 1-5 Not applicable if reporting anonymously 6. Date of Incident: 7. Date 8. Date of Report: 9. Patient Involved? Yes / No (please delete) 10. Age: 11. Sex: 12. Medication Incident? Yes / No (please delete) 13. If Yes please give name (s) of medication involved: 14. Other HSC Organisation Involved? Yes / No (please delete) 15. More details on HSC organisation (if willing to provide them) 16. Brief summary of incident (Should not contain personal detail of patient) Include relevant information regarding the incident eg name, form, dose and quantity of medications prescribed and same for those dispensed (if different), whether the patient actually consumed the medication and any harm that occurred. 16a Please indicate whether this was a ‘near miss’ or a dispensing error: □ near miss □ dispensing error □ other ‘Near miss’ is defined as an incident detected up to and including the point at which the medication was handed over to the patient or patient’s representative. Dispensing error is an incident detected after the patient had taken possession of the medication. 16b Level of harm and likelihood of re-occurrence: † See risk analysis table (Appendix 1) for definitions of these terms If harm occurred please indicate the actual level of harm† caused to the patient by this incident: Insignificant □ □ moderate □ major □ Catastrophic □ unknown □ n/a □
Anonymised-Community-Pharmacy-AI-Form-Sept-2016.docx