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Incidents
Datix Cymru Concerns Management System
Incident Reporting Form
(V4C)
** Logged Out Form **
Incident Affecting?
Who was affected?
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People Affected
When did the incident happen
Incident date
(dd/mm/yyyy)
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Time
(hh:mm)
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Reported Date
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Responsible Service
This is the Service responsible for ensuring that this incident is reviewed, investigated, and closed
Incident Service
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Confirm Exact Service?
Please confirm the exact service
I confirm this is the exact service
Where did the Incident happen?
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
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Does this incident need external reporting?
Certain incidents and events are reportable to external agencies such as the 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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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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Was absconder detained under the Mental Health Act?
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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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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
Is this Incident related to EPMA (Electronic Prescribing and Medicines Administration)?
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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 there any factor relating to Emergency Planning for the Incident?
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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 relates to the NHS Wales Nurse Staffing Act and appropriate staffing level and skill mix
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IPC antigens
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Were temporary staff involved in the incident?
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Was any other contact involved in the incident?
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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
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Who have you informed of the incident?
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Please select which 'Other NHS Body' has been informed
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Other NHS Body, please provide more detail
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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
Equipment
Blood Transfusion
Violence and Aggression Incidents
Contacts
Openness and Transparency
Documents
Are there any documents to be attached to this record?
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Documents
Details of person reporting the incident
Reporter
Clear section
ID
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Contact Role
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Reporter
Forenames
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Surname
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Email
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Work Telephone Number
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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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ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE
DO NOT DOUBLE CLICK
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