Patient Safety Incident report form - Scotland

This form is to be used to record details of medication safety incidents that are related to errors and near misses that occur within the pharmacy. This form does not count as formal notification of a dispensing error to the NPA as your indemnity provider; this should be done separately by telephone if appropriate. Patient information should not be included in this electronic form.
The NPA Scottish Patient Safety Incident Reporting Service is currently available to all members of community pharmacy teams in Scotland using the specific Scotland Reporting Form for 'near miss' and 'error' patient safety incidents. The anonymised reports will be reviewed for trends at least twice a year with a summary NPA Scottish Patient Safety Incident Report published to share learning.

Optional questions - for pharmacy use only
Reference number:
(e.g. 2016/01 for first incident)
Reporters name:
Job title:
Name of staff involved in the incident:
Staff employment status:
Role in incident:
Name of staff involved in the incident:
Staff employment status:
Role in incident:
Patient Information
Details of main patient affected by the incident: Do not complete this section now. To be completed after printing this form.
Name:
Date of birth
DD slash MM slash YYYY
Telephone number:
Gender:
Ethnic origin:
Address:
Time of incident

Hours :

Minutes
If the patient took/used the medicine/medical device, what symptoms did they experience?
Action requested by the patient?
- No action
- Phone call
- Letter
Responsible pharmacist notified?
- Yes
- No
Superintendent pharmacist notified?
- Yes
- No
CAPTCHA
Printing this page
If you have opted to have this form emailed to you, you will need to add in the patient details by hand. You can either print off the email and write the information onto it, or print off this page and complete the relevant sections. If you have not opted to have the form emailed to you, you will need to print off this page for your own records and add in the patient details in the relevant sections.
To print this form right click on your mouse and select 'print' from the menu.
If you are using an Apple Mac computer without use of a 'mouse' you can press Command + P to print
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Patient Safety Incident report form – Scotland