The Patient Safety Incident Reporting Form is a crucial document used across Irish healthcare facilities to ensure standardized reporting of patient safety incidents, adverse events, and near-misses. This form has been developed in accordance with Irish healthcare legislation, particularly the Patient Safety (Notifiable Patient Safety Incidents) Act 2023, and HSE guidelines. It is designed to capture comprehensive information about incidents while maintaining patient privacy under GDPR requirements. Healthcare providers must complete this form when any patient safety incident occurs, enabling proper documentation, analysis, and follow-up actions. The form supports both mandatory reporting obligations and internal quality improvement processes, helping healthcare organizations maintain high safety standards and comply with regulatory requirements.
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1. Reporter Information: Details of the person reporting the incident, including name, role, contact information, and relationship to the incident
2. Incident Details: Core information about the incident including date, time, location, and type of incident
3. Patient Information: Relevant patient details including identifier, age, gender, and current status (maintaining GDPR compliance)
4. Incident Description: Detailed narrative of what happened, including sequence of events and immediate actions taken
5. Severity Assessment: Assessment of the incident's severity using standardized criteria and impact on patient
6. Immediate Actions Taken: Description of actions taken immediately following the incident to ensure patient safety
7. Witness Information: Details of any witnesses to the incident, including staff members and other patients
8. Notification Details: Record of who has been notified about the incident (e.g., supervisors, medical team, family)
9. Initial Risk Assessment: Preliminary assessment of risks and potential consequences
1. Equipment Involved: Details of any medical equipment involved in the incident - to be included when incident involves medical devices or equipment
2. Medication Details: Specific information about medications involved - required for medication-related incidents
3. Environmental Factors: Description of environmental conditions that may have contributed - relevant for falls or facility-related incidents
4. Staff Factors: Information about staffing levels or staff-related factors - included when organizational factors may have contributed
5. Communication Issues: Details of any communication breakdowns - relevant when communication was a contributing factor
6. Patient/Family Feedback: Documentation of any immediate feedback from patient or family - included when immediate responses were received
1. Appendix A: Severity Classification Guide: Reference guide for standardized severity assessment criteria
2. Appendix B: Incident Category Codes: List of standardized incident classification codes for proper categorization
3. Appendix C: Notification Requirements: Guidelines on who must be notified based on incident type and severity
4. Appendix D: Follow-up Action Checklist: Standardized checklist for required follow-up actions based on incident type
5. Appendix E: Related Policy References: References to relevant hospital policies and procedures
6. Appendix F: Regulatory Reporting Requirements: Guide to mandatory reporting requirements under Irish law
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