Submit an Incident Report

Use the form below to report an incident. None of the fields are compulsory but the more information you provide the more useful the report. Please avoid submitting any details which could indentify an individual.

Part 1: Who was involved
Who is making the report:
Patient(s):

Age:
Ethnicity:
Where did the incident occur:
Part 2: What happened
Please describe the incident

Including the following would be helpful; a description of what happened, how it was detected, what the outcomes were for both the patient and the healthcare professional, and what if any actions were taken to rectify the problem.


It would be helpful if you could try to classify the incident using the categories below. Not all incidents will be easily categorised, please choose what you consider to be the closest match.
 
   
Staff were:
Patient was:
Process:
Problem:
Document involved:
Problem with document:
Medication involved:
Medication use/Process:
Problem:
Type of device/property
Problem:
Part 3: Prevention

Please describe any changes made to try and prevent this type of incident occurring again?

Are there any systemic changes that could be made or checks put in place that might prevent this type of incident occurring elsewhere?

 

© BPAC NZ March 2010