HOW TO COMPLETE AN INCIDENT REPORT FORM
Please note that this form is intended to be formally printed these printed pads are currently being distributed throughout the organisation. There are two pages on these pads the first the original incident report form and the second the investigation report. In the pads these forms are printed back to back and carbonated. They are also colour coded (front sheet white and investigation sheet yellow) hence they are labelled as such on these copies.
Incident Form (Sections 1 - 10) (White Copy)
Please use black ink for the completion of the form as black ink photocopies and scans well. There are six mandatory fields (if you have a colour printed these are highlighted in red) on the IR form (IRF) which must be completed for all Incidents by the member of staff reporting the incident: Person completing the form to include name, job title, contact number and base. Person affected by the incident type and severity of the incident Description of the Incident location Details of the incident Actions taken at the time of the incident
Please note that witness details are only to be completed if the incident was actually witnessed . Section 1. Person completing the form
The full details of the person completing the form should be added. The necessity for this is so that the local manager and/or risk manager can contact that person should further details of the incident be required and also to ensure that feedback is given following incident investigation. Please provide your base details, (I.e. the Health centre, Office which is considered your base.) Section 2. Line Manager
Name and contact details for the reporting member of staff’s line manager must be added here as the line manager is responsible for reviewing, investigating and providing feedback to staff on the incident. The Risk Management Department will liaise with the stated line manager using the contact details given.
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Section 3/4. Person affected by the incident This section needs to be completed for the person affected by the incident. If it is a patient who is affected then a staff member needs to insert the patient’s details. A patient’s NHS/hospital number needs to be added, as this will aid Risk Management Department in following up patient injuries.
Many incidents may affect both a patient and a staff member, in circumstances such as this it is necessary for details of both to be added to the form. One person’s details can be added to the person affected section and the other person’s details should be added to the ‘Details of Incident’ section or onto the separate sheet. Multiple people may be affected by an incident, and it may be necessary to fill the form on behalf of a whole ward or department e.g. Jersey Ward, or Audiology Department. Section 5. Type of Incident
A tick box description of the type of incident needs to be noted here. Confirm the severity of incident by referring to the Trust’s Risk Matrix, see reverse of the incident form please tick the severity of the incident. If you are printing the form from the website this is on page 3 of the form. Section 6. Incident Location
The date, time, directorate, site, area and exact location of the incident are written here. By completing all these fields it is possible to pick up trends in reporting, e.g. unavailability of staff. The incident forms can assist the directorates to identify patterns, and then look at ways to manage the risks identified. If another area is involved in the incident, please add them to the ‘Details of Incident’ section. The area reporting the incident should communicate with the other area involved to enable them to take immediate action to rectify the situation. It will also allow Risk Management Department to provide additional feedback to these areas, so they can take any further corrective action. Section 7. Description of the Incident
A brief description of the incident is needed in this box. What was the incident? Be factual and concise in the description. If more space is required then please use additional sheets. Make sure the additional pages are numbered, named and dated at top of the sheets. If you are using the pre-printed additional pages please ensure that the unique number from the incident form is added to the top of the sheet. This will aid the local manager and or Risk Management Department should the sheets become loose. Details of additional witnesses and witness statements should be taken and attached to the form if appropriate. Make sure the content of the statements are factual and not subjective, and that they are named, signed and dated. Injuries - Were any injuries sustained in the incident? If so what type of injury e.g. laceration, pressure sore, fracture. Did the injured person receive medical attention? Who gave treatment? E.g. nursing/medical staff on the ward, a first-aider or the
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Accident & Emergency Department etc? If the person affected by the incident, was a member of staff, was counselling offered? Property / Equipment - Was there any property / equipment involved in the incident? Has the asset number been recorded? Please take the equipment out of circulation, label it and do not use it until the equipment is fixed. Inform the appropriate department or Production Company if repair or maintenance is required. Type of incident - If the Incident involves as Pressure Ulcer, a Surgical site infection, Medication, Equipment please complete additional information found on the reverse of the front page. Section 8. Actions taken at the time of the incident
Please indicate on the IRF who has been notified of the incident. Please contact the Health and Safety Manager for information on the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) or access the RIDDOR website www.hse.gov.uk/riddor Section 9. Please sign and date the form. Section 10. The risk rating. (Potential severity x likelihood of recurrence). What in your opinion is the potential consequence/ likelihood of recurrence of the reported incident (Put a cross in the box as applicable) see overleaf for explanation of consequence & likelihood. As soon as sections 1 – 10 have been completed please fax the IR Form to the Database Administrator on 01202 853342 within 24 hours of the incident occurring. The original form should also be forwarded to your line manager or senior manager on call if out of hours within 24 hours of the incident or immediately for incidents graded ‘high’ on the risk calculator Upon receipt of the completed form the Database Administrator will: designate the incident a number and write it by hand on the faxed IR form scan the faxed IRF e-mail the IRF to the line manager of the person completing the form
Incident investigation. (Yellow Copy)
Please ensure that the front part of this is completed and sent to your line manager. Incident Investigation Form (Sections A- C) Sections A – C must be completed by the line manager The number at the top left of the IRS form can be used to assist Managers in identifying each specific incident reported and noted on their local risk register. The same number will also be used if the incident is added to the corporate risk register.
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Section A.
Comments on incident & subsequent actions
In this section the line manager should document: their assessment of the incident (based on the facts known) the control measures put in place action plan (if appropriate) investigation arrangements (if graded as moderate or high an investigation must be carried out. If low, investigation may be required if the Manager feels this is necessary e.g. if trend analysis indicates this is required).
Please review the Incident Occurrence Flowchart (Appendix F of the Incident reporting and investigation policy) and the Incident Process table (Appendix G Incident reporting and investigation policy) for further information on the processes and timescales to be followed following an incident Section B. Line Manager Information
The line managers name, designation and date that sections A - B were completed must be stated here. This will ensure that any future correspondence from the Risk Management Department is directed to the correct person Section C. Risk Register
confirm whether the risk rating initially graded (at section 4) has been regarded. If so write the new grade in the blank space. confirm that the incident has been added to the local risk register and/or the Corporate risk Register
Feedback Any actions taken should be fed back to staff. Please refer to Incident Occurrence Flowchart (Appendix F Incident reporting and investigation policy) and the Incident Process table (Appendix G Incident reporting and investigation policy) for further information on the processes and timescales to be followed following an incident IR Forms Must Not Be Filed In the Medical Records. Where staff are unsure whether an incident should be reported, please contact your line manager or telephone the IR hotline on 01202 853341 or 853342.
THE PCT TAKE THE VIEW THAT IT IS ALWAYS BETTER TO REPORT THE INCIDENT
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