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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?
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  - 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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  - Exact location
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1. Incident Severity
2. - 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
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  - 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.
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  - If the patient took/used the medicine/medical device, what symptoms did they experience?
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  - Managers Interim Harm Assessment
    The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please click here
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  - 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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1. Incident Details/What Happened
2. - 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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1. Incident Type
2. - 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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1. Perpetrator
1. Restrictive Practice
1. Additional Information
2. - Was any equipment involved in the incident?
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  - Did medication have a direct impact on this incident?
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  - Was a Controlled Drug involved?
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    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?
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  - if yes, what process(es) were or will be followed?
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  - Is this related to Coronavirus/COVID 19
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  - Is this related to Industrial Action?
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  - Date of Industrial Action
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  - Further information pertinent to Industrial Action
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  - Is this incident about nursing care?
    This section relates to NHS Wales Nurse Staffing Act and appropriate staffing levels and skill mix
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  - IPC antigens
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  - Was any other contact involved in the incident?
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1. Information Governance
1. Communication
2. - 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.
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  - Who have you informed of the incident?
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    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
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    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
1. Medications
1. Equipment
1. Blood Transfusion
1. Violence and Aggression Incidents
1. Contacts
1. Openness and Transparency
1. Duty of Candour (DoC)
1. Duty of Candour - Initial Notification
1. Duty of Candour - Written Notification and Investigation Response
1. Documents
2. - Are there any documents to be attached to this record?
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1. Documents
1. Yorkshire Contributory Factors Framework
1. Domain 1: Situational Factors
2. - Team Factors: Was there any failure of 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
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  - 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
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    Yes
    No
    Maybe
  - Notes
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  - Task characteristics: Did the task features make the incident more likely?
    For example; unfamiliar task, monotonous task, difficult task
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    Yes
    No
    Maybe
  - Notes
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  - 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
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1. Domain 2: Local Working Conditions
2. - 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
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1. Domain 3: Organisational Factors
2. - 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.
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    Yes
    No
    Maybe
  - Notes
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  - 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
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    Yes
    No
    Maybe
  - Notes
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  - 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
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1. Domain 4: External Factors
2. - 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
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  - 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
1. Domain 5: Communication and Culture
2. - 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
1. Causal Factors Framework Summary
2. - Which are the most important contributory factors for this incident?
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1. Conclusion
2. - 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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1. Details of person reporting the incident
1. Additional Reporter Details
2. - 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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