Contacts Local: Clare.moody@nhs.net 01480 387 114 Regional NHS England CDAO England.ea-cdao@nhs.net

ANY and ALL CD related incidents and errors www.cdreporting.co.uk Whenever something involving CDs (any schedule) doesn’t go according to plan Dispensing error – wrong brand, wrong strength, wrong quantity, wrong patient (GDPR – apologise!), expired script, lost script…….. Dropped or broken item – if S2 will need to be contained until authorised witness can attend You can also report problems that you have identified at other organisations – posted script from substance misuse not arrived? not happy about someone’s prescribing habits (large doses, inappropriate titration, large quantities, weird products…..) let us know! I really don’t like it when I attend the meetings of the local intelligence network and another organisation (substance misuse, usually) submits a lists of pharmacy errors that I don’t know anything about.

If you haven’t used the website before, you will first need to register – quick and free. During registration you will be asked for an email address. Shared email accounts can only be used once. Use a work email if you have one.

Report form I receive an automated notification that you have completed an incident. The incident report contains your contact details and you should expected an email from me within a few days – I may also call you, but any call will be followed by an email (I need an audit trail). I am highly likely to request more information, to ask about your SOPs, to have a near heart attack and demand a root cause analysis. At any one time I usually have 30 or so open incidents and most of these are waiting for more information from the reporter. I can’t close incidents until the CDAO process is completed, I would really appreciate timely responses. As part of your internal investigation you should already have the answers to my questions, if you have it is imperative that your investigation is stepped up / reopened. Filing an incident is not the end of the process. The CDAO requires assurance that you have learnt, that you have closed loop holes, updated your SOPs, trained your staff, that our POPULATION IS SAFE. The same applies if you report concerns about someone else – I will contact them for a full explanation.

Destruction request While we’re talking about the website, please also use to request a witness for destruction