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
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.
Please enter your ODS practice code
Share with CCG
Please describe what happened?*
Please enter the date on which the event occurred*
Please enter the location in which the incident occurred*
GP Surgery - DispensaryGP Surgery - Treatment / consulting roomGP Surgery - Waiting room / receptionGP Surgery - Other
Community hospitalGeneral / acute hospitalMental health unit / facilityPrimary care settingPublic place (specify)Residence / homeSocial care facilityNot applicableUnknownOther
Please categorise the Patient Safety Incident from the following choices*
At what stage during the medication process did the actual or potential error occur?*
For this patient safety incident involving medicine, please select the appropriate description*
What is the approved drug name of the medicines?*
Please select from the following choices to indicate the type of device*
Additional information for Patient Safety incident involving medication
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.
Proprietary (trade) name
Dose and strength
Wrong dose and strength
Intended dose and strength
British National Formulary (BNF) classification (1-15)
Dose and strength
Additional information for Patient Safety incident involving Medical Device or Equipment
Current location of the device(s)
Was this incident a never event?
Was the incident shared or discussed with the patient, carer and/or family?
Using the following grading, please indicate the degree of harm to the patient*
Please use only one of the following options to add the age of the patient at the time the incident occurred*
What is the sex of the patient?*
Please select the staff group that you belong to*
General practitioner (GP)General practitioner (GP) - registrarMedical studentOther
Ambulance staffDiagnostic and therapeutic staffManagerNurse / midwife / health visitorPharmacy staffSupport staff (clinical and administration)UnknownOther
Insert your email address to receive email confirmation and an SEA template for
CPD, Appraisal and Revalidation
Please note that you can save and print the form after it has been submitted, not
Terms & conditions of use | Freedom of Information | Information Governance