DCIQ: 18 Week Support Incident Reporting Form

18 Week Support Incident Reporting Form

18 Week Support strongly encourages all staff to actively report all incidents and near misses; this strengthens our learning culture and helps to continually improve.

Any incident or near miss that occurs within an NHS or clinical service setting needs to be double reported on the Trust’s own Datix too please.

This form is designed to be user friendly and intuitive to use, it may ask you some additional questions based on the answers and detail you give.

Any field with * is a mandatory field and must be completed before the form can be submitted

All reported incidents are reviewed by the governance team within 3 working days of submission and allocated to the appropriate manager to investigate.
Learning is discussed and actions monitored through Department Governance committees.

Thank you
Last updated 26.06.2024

1. Incident Details
2. - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Incident headline
    One line brief of what the incident is i.e. misdiagnosis of cancer, needlestick injury to staff member, report discrepancy.
    You must enter a value in this field
  - Description
    Please provide as much detail of the incident as possible, bullet point important facts. DO NOT write NAMES of Individuals.
    You must enter a value in this field
  - Immediate action taken
    Please add details of any immediate action taken when the incident was identified, to include actions taken to resolve, correct, maintain safety or service provision
    +/- if and how this incident was escalated
    You must enter a value in this field
  - Do you have the Trust Datix/incident reference number?
    You must enter a value in this field
  - Trust / NHS Datix ID
    You must enter a value in this field
1. People Affected
1. 18WS Staff
1. Additional Information
2. - Add anyone else who was involved or witnessed the incident?
    You must enter a value in this field
1. Contacts
1. Location & Service
2. - Location
    You must enter a value in this field
  - Site
    You must enter a value in this field
  - Service/Department
    You must enter a value in this field
  - Area
    You must enter a value in this field
1. Incident Coding
2. - Who or what did this incident affect?
    You must enter a value in this field
  - Category
    You must enter a value in this field
  - Sub category
    You must enter a value in this field
  - Is this in relation to a safeguarding concern?
    You must enter a value in this field
1. Level of Harm/Severity
2. - Result
    You must enter a value in this field
  - Level of harm
    Harm caused by the incident (by an action or omission)
    You must enter a value in this field
1. Duty of Candour
  
  In relation to statutory Duty of Candour (DoC) for patient safety incidents that resulted in moderate harm or above
1. Documents
2. - Drag and drop
    or
1. Details of person reporting the incident

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18 Week Support Incident Reporting Form