DCIQ: Datix Cymru Concerns Management System Incident Reporting Form (V4C)**Logged Out Form**

Datix Cymru Concerns Management System

Incident Reporting Form (V4C)

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. Responsible Service
  
  This is the Service responsible for ensuring that this incident is reviewed, investigated, and closed
2. - Incident Service
    To select a service start typing – EMS / NEPTS / 111 / CCC / HART etc and select one from the list
    You must enter a value in this field
1. Where did the incident happen?
2. - Location of Incident
    To select a location by typing - residence / public / care home / GP / vehicle / in transit etc
    You must enter a value in this field
  - Exact location
    This is a free text field – type the full location
    You must enter a value in this field
1. Incident Details/What Happened
2. - 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
1. Incident Severity
2. - Reporters view on level of harm
    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 click here
    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
1. Incident Type
2. - 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
1. Perpetrator
1. Restrictive Practice
1. Additional Information
2. - 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
    Business Continuity
    Covid-19
    Industrial Action
    Major Incident
    No
  - 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
1. Information Governance
1. Communication
2. - 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
1. 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.
1. Details of "other drug" involved in the incident
1. Equipment
1. Blood Transfusion
1. Violence and Aggression Incidents
1. Contacts
1. Openness and Transparency
1. Documents
2. - Are there any documents to be attached to this record?
    You must enter a value in this field
1. Documents
1. Details of person reporting the incident
1. Additional Reporter Details
2. - Reporters Location
    This would be your usual place of work
    You must enter a value in this field
  - Reporters Service
    This would be the Service/Dept in which you work/are employed
    You must enter a value in this field
1. 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 (V4C)**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 (V4C)

Logged Out Form

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

DO NOT DOUBLE CLICK