This form is designed for use by general practitioners, practice nurses and general practice staff to report patient safety incidents to the National Reporting and Learning System. This includes near misses and incidents where there is a beneficial outcome, for example where systems and processes have successfully prevented an untoward incident.

Submitted reports are analysed for themes and trends to support national learning and sharing of good practice.


If the incident that you are reporting relates to safeguarding, whistleblowing or other incident type where separate policies for notification exist, these must be followed in addition to completing this eform.

If you are reporting a Serious Incident requiring notification to the NHS England Sub Region (previously the Area Team), please include your practice ODS code and this report will be automatically shared with your NHS England Sub Region.

Please do not include any person identifiable information in your report.

Incident details

*Mandatory |Help

Q1

Please enter your ODS practice code

Practice Name:

Q2

Please describe what happened?*

Q3

Please enter the date on which the event occurred*

Q4

Please enter the location in which the incident occurred*

Q5

Please categorise the Patient Safety Incident from the following choices*

Q5.1

At what stage during the medication process did the actual or potential error occur?*

Q5.2

For this patient safety incident involving medicine, please select the appropriate description*

Q5.3

What is the approved drug name of the medicines?*

Q5.3

What is the approved drug name of the medicines?*

Q5.1

Please select from the following choices to indicate the type of device*

Additional information for Patient Safety incident involving medication

Q5a

Were there other important factors? If so, please select one or more from the following choices

Hold down CTRL key to select more than one item.

Q5b

Proprietary (trade) name

Q5c

Formulation

Q5c1

Wrong Formulation

Q5c2

Intended Formulation

Q5d

Dose and strength

Q5d1

Wrong dose and strength

Q5d2

Intended dose and strength

Q5e1

Wrong route

Q5e2

Intended route

Q5e

Route

Q5f

British National Formulary (BNF) classification (1-15)

Q5g

Manufacturer

Q5h

Batch number

Q5b

Proprietary (trade) name

Q5c

Formulation

Q5d

Dose and strength

Q5e

Route

Q5f

British National Formulary (BNF) classification (1-15)

Q5g

Manufacturer

Q5h

Batch number

Additional information for Patient Safety incident involving Medical Device or Equipment

Q5a

Current location of the device(s)

Q5b

Product name

Q5c

Model

Q5d

Catalogue number

Q5e

Serial number

Q5f

Manufacturer

Q5g

Supplier

Q5h

Batch number

Q5i

Expiry date

Q5j

Date manufactured

Q5k

Quantity defective

Q6

Was this incident a never event?

Q7

Was the incident shared or discussed with the patient, carer and/or family?

Q8

Using the following grading, please indicate the degree of harm to the patient*

Q9

Please use only one of the following options to add the age of the patient at the time the incident occurred*

or
or

Q10

What is the sex of the patient?*

Q11

Please select the staff group that you belong to*

Q12

Please note that you can save and print the form after it has been submitted, not before.