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Incidents

Datix Cymru Concerns Management System

Incident Reporting Form (V4A)

Pharmacy - Logged Out Form

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

Exact location

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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 click here
  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
- Managers Interim Harm Assessment
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please click here
  You must enter a value in this field
- Following the initial review, has the grading changed?
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- Please explain why the grading has changed since the record was submitted
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- Was the healthcare provided a factor or may it have been a factor in a Patient/Service user suffering harm?
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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
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- 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
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- Vehicle Registration Number
  Where a vehicle was involved in the incident
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- Booking or CAS Number if applicable (WAST)
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- Laboratory Specimen Number
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Incident Type
- Classification
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- Category
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- Sub Category
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- You have selected 'Other' - Please tell us what Sub Subtype option is missing from the system
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- Fire Additional Options
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- Fire alarm activation: Additional Options
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- Was a ligature used?
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- Method violence and aggression was received by
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- Has a Perpetrator been identified?
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- Please provide as much information that is known about the perpetrator
  e.g. description of perpetrator
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Perpetrator

Restrictive Practice

Additional Information
- Was any equipment involved in the incident?
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- Was there any medication involved?
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- Was a Controlled Drug involved?
  You must enter a value in this field
  - Yes
  - No
  - Don't Know
- 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
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- 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 this related to Coronavirus/COVID 19
  You must enter a value in this field
- Is this related to Industrial Action?
  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
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- Is this incident about 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
- Was any other contact involved in the incident?
  You must enter a value in this field

Information Governance

Communication
- Is this incident of a sensitive nature and 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
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- Who have you informed of the incident?
  You must enter a value in this field
  - Line Manager
  - HB - Safeguarding
  - Estates
  - Hotel Services
  - Lead clinician
  - Patient Safety
  - Health & Safety
  - Security Team
  - Police
  - Fire Safety
  - Occupational Health
  - Communication Department
  - Human Resources
  - Relatives
  - Counter fraud Team
  - Local Authority - Safeguarding
  - Nobody Informed
  - Other NHS Body
  - Governance Team
  - Bed Management
  - Coroner
  - Fleet/Transport Dept
  - GP/OOHS
  - Major Trauma Service
  - Resus Team
  - University (Student Placements Office)
- Please select which 'Other NHS Body' has been informed
  You must enter a value in this field
  - Aneurin Bevan UHB
  - Betsi Cadwaladwr UHB
  - Cardiff and Vale UHB
  - Cwm Taf Morgannwg UHB
  - Digital Health and Care Wales
  - Hywel Dda UHB
  - Powys Teaching HB
  - Public Health Wales
  - Swansea Bay UHB
  - Velindre University NHS Trust
  - Welsh Ambulance Service Trust

Medications
- Please add medication below, if you are unable to find name in medication section
  You must enter a value in this field

Equipment

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?
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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
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  - 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?
  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
- Scheduling and Bed Management: Did any time or bed pressures play a role in the incident? 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?
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Conclusion
- Is this incident related to the five harms of Covid 19?
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- Post Investigation Harm Assessment
  This field should record the final assessment of harm caused by the organisation following investigation
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please click here
  You must enter a value in this field
- Result
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- Lessons learned
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Details of person reporting the incident

Additional Reporter Details
- Reporters Location
  This would be your usual place of work
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- Reporters Service
  This would be Service/Dept in which you work/are employed
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