2. Incident Report Form Training Presentation Risk Department 6 Sterne Road Tatchbury Mount Calmore SO40 2RZ 023 8087 4323

3. This Presentation This presentation will guide you though each part of the form. It will show you how to fill it in and what information you will need to do so. It will also explain which bits you may not need to complete.

4. The Incident Form

5. We will now work through each section of the form in turn and explain what goes where.

6. Part A1 – Primary person affected (Patient/Staff Details)

7. Write the details of the person involved or affected by the incident here. Ensure all details are provided.

8. Part A1 – Primary person affected (Patient/Staff Details) Don’t forget to identify whether it is a patient or a member of staff.

9. Part A1 – Primary person affected (Patient/Staff Details) Remember to include the patient’s NHS number

10. Part A2 – Other person affected If other people have been involved in the incident, record their details here in section A2.

11. Part A2 – Other person affected If other people have been involved in the incident, record their details here in section A2. If more than one person is involved, please write their details on the ‘incident information form’ that can be found on the web page.

12. Part B – Person completing this form Please tell us who you are and provide a FULL contact number. This is in case we need to contact you for more information.

13. Part C – The incident Please write your account of the incident (facts only) in this section. Include any injuries that were sustained here.

14. Part C – The incident You must not put names or initials in this section. You need to identify using P1, P2 (etc) for patients and S1, S2 (etc) for staff.

15. Part D – Witnesses to the incident Complete this section if the incident was witnessed by other people. Please include a FULL contact number, in case we need to contact them for further information.

16. Part E – Where and when the incident or near miss occured Please state which service your are reporting the incident from.

17. Part E – Where and when the incident or near miss occurred Please indicate the location of where the incident happened. (Where possible, please include the room number).

18. Part E – Where and when the incident or near miss occured Here you must fill in the date the incident took place and a time (an approx time can be used if you are not sure of the exact time).

19. Part F – Grading of immediately apparent consequence(s) In this part we want you to assess the result of the incident. (Refer to the front of the incident book for the guidelines).

20. Part F – Grading of immediately apparent consequence(s) In this part we want you to assess the result of the incident. (Refer to the front of the incident book for the guidelines). All Red incidents must be reported to the Risk Department immediately.

21. Part G – Cause of incident Briefly explain why the incident happened.

22. Part H – Immediate action(s) taken In this section you need to say what you did in the first instance.

23. Part H – Immediate action(s) taken The last section is for your line manager to fill in. This is to record the proposed action to be taken to prevent similar incidents.

24. Part H – Immediate action(s) taken Once completed, the relevant form must be distributed as per these instructions.

25. Congratulations You have now completed the presentation If you need further assistance to complete a form contact the risk team. Risk Department 6 Sterne Road Tatchbury Mount Calmore SO40 2RZ 023 8087 4323