DCIQ: Datix Cymru Concerns Management System Incident Reporting Form (V5A)***Optometry

Datix Cymru Concerns Management System

Incident Reporting Form (V5A)

Optometry - Logged Out Form

1. Incident Affecting?
2. - Who was affected?
    You must enter a value in this field
1. People Affected
1. When did the incident happen
2. - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Time (hh:mm)
    You must enter a value in this field
  - Reported Date
    You must enter a value in this field
1. Where did the incident happen?
2. - Location of Incident
    You must enter a value in this field
  - Confirm Exact Location?
    Please confirm the exact location
    
    I confirm this is the exact location

Exact location

Incident Severity
- Reporter's initial harm assessment
  This incident is graded on potential harm caused by the Health Body
  The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please right click over the underlined text and select 'open link in new window.' Grading Framework
  You must enter a value in this field
- Does this incident need external reporting?
  Certain incidents and events are reportable to external agencies such as the NHS Wales Executive, Welsh Government, Health and Safety Executive (HSE) including RIDDOR, Medicines Healthcare Regulatory Agency (MHRA), Never Events and SMTL
  You must enter a value in this field

Incident Details/What Happened
- Description
  Please provide a brief description of the incident ensuring that no identifiable information is included in this box.
  Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP
  You must enter a value in this field
- Brief Description of Actions Taken
  Please provide a brief description of any immediate action taken, ensuring that no identifiable information is included in this box.
  Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP
  You must enter a value in this field
- Vehicle Registration Number
  Where a vehicle was involved in the incident
  You must enter a value in this field
- Booking or CAS Number if applicable (WAST)
  You must enter a value in this field
- Laboratory Specimen Number
  You must enter a value in this field

Incident Type
- Classification
  You must enter a value in this field
- Category
  You must enter a value in this field
- Sub Category
  You must enter a value in this field
- You have selected 'Other' - Please tell us what Sub Subtype option is missing from the system
  You must enter a value in this field
- Fire Additional Options
  You must enter a value in this field
- Fire alarm activation: Additional Options
  You must enter a value in this field
- Was a ligature used?
  You must enter a value in this field
- Method violence and aggression was received by
  You must enter a value in this field
- Was absconder detained under the Mental Health Act?
  You must enter a value in this field
- Has a Perpetrator been identified?
  You must enter a value in this field
- Please provide as much information that is known about the perpetrator
  e.g. description of perpetrator
  You must enter a value in this field

Perpetrator

Restrictive Practice

Additional Information
- Was any equipment involved in the incident?
  You must enter a value in this field
- Did medication have a direct impact on this incident?
  You must enter a value in this field
- Was a Controlled Drug involved?
  You must enter a value in this field
  - Yes
  - No
  - Don't Know
- Is this Incident related to EPMA (Electronic Prescribing and Medicines Administration)?
  You must enter a value in this field
- Does this incident have Information Governance considerations?
  The answer should be 'yes' if the incident involves personal or sensitive data, including near misses. For example, a breach of confidentiality, theft, loss or misuse of personal data, information security, etc. For further advice, please contact your information governance team
  You must enter a value in this field
- Does this incident have any safeguarding elements?
  You must enter a value in this field
- if yes, what process(es) were or will be followed?
  You must enter a value in this field
- Is there any factor relating to Emergency Planning for the Incident?
  You must enter a value in this field
- Date of Industrial Action
  You must enter a value in this field
- Further information pertinent to Industrial action
  You must enter a value in this field
- Is this incident about nursing care?
  This relates to the NHS Wales Nurse Staffing Act and appropriate staffing level and skill mix
  You must enter a value in this field
- IPC antigens
  You must enter a value in this field
- Were temporary staff involved in the incident?
  You must enter a value in this field
- Was any other contact involved in the incident?
  You must enter a value in this field

Information Governance

Communication
- Is this incident highly confidential (not for circulation)?
  This may include highly confidential information (staff/service user/patient) which requires restricted access. This may include Freedom to Speak up Safely
  You must enter a value in this field
- Who have you informed of the incident?
  You must enter a value in this field
- Please select which 'Other NHS Body' has been informed
  You must enter a value in this field
- Other NHS Body, please provide more detail
  You must enter a value in this field

Medications

When searching for drug ‘administered/omitted’ or ‘intended/suspected’, if you are unable to find the medication involved in the incident please search for ‘other drug’ and select ‘other Drug not listed’. You will then be required to enter details of the medication in the section: Details of ‘other drug’ involved in the incident.

Details of "other drug" involved in the incident

Equipment

Blood Transfusion

Violence and Aggression Incidents

Contacts

Openness and Transparency

Documents
- Are there any documents to be attached to this record?
  You must enter a value in this field

Documents

Details of person reporting the incident

Additional Reporter Details
- Reporters Location
  This would be your usual place of work
  You must enter a value in this field
- Reporters Service
  This would be Service/Dept in which you work/are employed
  You must enter a value in this field

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE

DO NOT DOUBLE CLICK

Incidents

Datix Cymru Concerns Management System Incident Reporting Form (V5A)***Optometry - Logged Out Form***

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCEDO NOT DOUBLE CLICK

Datix Cymru Concerns Management System

Incident Reporting Form (V5A)

Optometry - Logged Out Form

ON COMPLETION OF THE REPORTING FORM, PLEASE CLICK THE SAVE BUTTON ONCE

DO NOT DOUBLE CLICK