BDV - Adverse incident reporting form

Instructions for Completing the Adverse Incident Reporting Form Purpose The Adverse Incident Reporting Form is designed to document any adverse incidents that occur within the clinic to ensure patient safety and promote continuous improvement. This form must be completed in compliance with the Care Quality Commission (CQC) requirements. Frequency The form should be completed immediately following any adverse incident, ensuring timely documentation and appropriate follow-up actions. Relevant CQC Domains and Key Lines of Enquiry (KLOEs) This reporting process supports the following CQC domains and KLOEs: Safe (S) Safe (S) S1: How do systems, processes, and practices keep people safe and safeguarded from abuse? S2: How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe? S3: How does the service make sure that there are sufficient numbers of suitable staff to support the delivery of safe care and treatment? S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible? S4.1: How are medicines and medicines-related stationery managed (ordered, transported, stored, and disposed of safely and securely)? S4.2: Are medicines appropriately prescribed, administered, and/or supplied to people in line with the relevant legislation, current national guidance, or best available evidence? S4.3: Do people receive specific advice about their medicines in line with current national guidance or evidence? S4.4: How does the service make sure that people receive their medicines as intended, and is this recorded appropriately? S4.5: Are people's medicines reconciled in line with current national guidance when transferring between locations or changing levels of care? S4.6: Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence? S4.7: Are people's medicines regularly reviewed including the use of 'when required' medicines? S4.8: How does the service make sure that people's behaviour is not controlled by excessive or inappropriate use of medicines? S6: Are lessons learned and improvements made when things go wrong? Effective (E) E1: Are people’s needs assessed and care and treatment delivered in line with current legislation, standards, and evidence-based guidance? E2: How are people supported to live healthier lives and, where the service is responsible, how do they maintain their health and wellbeing? Caring (C) C1: How do staff involve and treat people with compassion, kindness, dignity, and respect? C2: How are people's privacy and dignity respected and promoted? Responsive (R) R1: How do services meet people's needs? R2: How are people’s concerns and complaints listened and responded to, and used to improve the quality of care? Well-led (W) W1: Is there the leadership capacity and capability to deliver high-quality, sustainable care? W2: Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver? W3: Is there a culture of high-quality, sustainable care? W4: Are there clear responsibilities, roles, and systems of accountability to support good governance and management? W5: Are there clear and effective processes for managing risks, issues, and performance? W6: Is appropriate and accurate information being effectively processed, challenged, and acted on? W7: Are the people who use services, the public, staff, and external partners engaged and involved to support high-quality sustainable services? W8: Are there robust systems and processes for learning, continuous improvement, and innovation? Steps for Completing the Adverse Incident Reporting Form 1. General Information - Fill in the date and time of the report. - Provide your name, position, department/unit, and contact information. 2. Incident Details - Record the date, time, and location of the incident. - Select the incident type from the provided options (e.g., Medication Error, Equipment Failure). - Provide a detailed description of the incident, including what happened, who was involved, and any immediate actions taken. - List any witnesses, including their names and contact information. 3. Patient Details (if applicable) - Include the patient’s name, date of birth - Indicate if the patient was informed about the incident and provide an explanation if not. 4. Immediate Actions Taken - Specify whether immediate medical attention was provided and describe the treatment. - Note if any emergency services were called, including which service and the time of the call. - Detail any immediate corrective actions taken to address the incident. 5. Root Cause Analysis - Provide an initial assessment of the cause of the incident. - List any contributing factors, such as human error or equipment malfunction. 6. Follow-Up Actions - Indicate if the incident was reported to a supervisor or manager, including their name and the date and time of the report. - Recommend any further actions to prevent recurrence of the incident. - Identify any training or education needs arising from the incident. 7. Reporting to Regulatory Authorities (if applicable) - Record if the incident was reported to any regulatory authority (e.g., CQC, MHRA), providing relevant details. 8. Signatures - Sign and date the form. - Obtain the signature and date from a supervisor or manager to confirm review. Important Considerations Confidentiality: Ensure all information is stored securely and confidentiality is maintained at all times. Timeliness: Complete the form as soon as possible after the incident to ensure accurate and timely documentation. Accuracy: Provide detailed and accurate information to facilitate effective follow-up and corrective actions. Evidence Use: Recognise that this report may be used as evidence if required. By following these instructions and using this form in accordance with clinic policies and relevant legal requirements, the clinic can ensure compliance with CQC standards and promote a culture of safety and continuous improvement. For more detailed guidance, refer to the CQC [Medicines Management](https://www.cqc.org.uk/guidance-providers/healthcare/medicines-management-healthcare-services) and [Key Lines of Enquiry for Healthcare Services](https://www.cqc.org.uk/guidance-providers/healthcare/key-lines-enquiry-healthcare-services.

Title Page

Conducted on
Prepared by
Location
Report sent as per policy framework in appendix

Incident Details

Date and time of incident
Location of incident
Incident Type
- Medication error
- Equipment failure
- Patient fall
- Infection control breach
- Staff injury
- Security breach
- Clinical incident
- Violence / aggression
- Needle stick injury
- Other *
Description of Incident - Provide a detailed description of the incident, including what happened, who was involved, and any immediate actions taken.
Witnesses (if any)

Patient details (if applicable)

Patient Name
Patient date of birth
Patient contact details
Was the patient informed about the incident?
Why was the patient not informed?
Does the patient require a follow up?

Evidence

Please provide any photographer evidence if appropriate (e.g if equipment broken, sharps bin overflowing)

Immediate actions taken

Was immediate medical attention provided?
Were any emergency services called?
Immediate corrective actions taken to address the incident:

Root cause analysis

Initial Assessment of Cause: Describe any initial thoughts on what may have caused the incident.
Contributing Factors: List any factors that may have contributed to the incident (e.g., human error, equipment malfunction, environmental factors).

Follow-Up Actions

Was the incident reported to a supervisor or manager?<br>
Name of supervisor / manager
Time and date reported to supervisor / manager

Level of harm

What was the potential level of harm from this incident?
What was the actual level of harm from this incident

Reporting to Regulatory Authorities (if applicable)

Was the incident reported to any regulatory authority (e.g., CQC, MHRA)?

This form should be stored securely and confidentiality must be maintained at all times. Use this form in accordance with BDV clinic’s policies and relevant legal requirements.