DCIQ: Croydon Health Services Incident Reporting Form

Croydon Health Services Incident Reporting Form

This form is used for reporting incidents (including near misses), FGM, Greatix, and Freedom to speak up.

Any equipment involved in the incident should have been retained in safe keeping for possible examination.

If you are unable to see the drop down buttons on the side please copy and paste link in to Chrome.

TO LOGIN IN TO REVEIW ANY INCIDENTS - The LOGIN Button at the top of the page now works
or use this Datixcloud IQ Login
(It will show an error message but just click back to login.)

To access the Trust's incident reporting policy click here:
Incident Management and Investigation Policy

To enter a mortality report please click on this link
Mortality Report form

To review any previous incidents submitted via Datixweb please log in on this link

https://web.datix.thirdparty.nhs.uk/croydon/live/index.php?action=login

You may need to have your paswword re-set as it has moved to a new server. Please contact the Datix team if that is the case.

For assistance with completing this form, please contact the Datix Team on ext. 3434, or email CH-TR.Datix@nhs.net

1. User Defined Section 1
2. - What type of report is this?
    You must enter a value in this field
    Incident
    FGM
    Freedom To Speak Up
    Greatix
    Make a difference
  - Is this a confidential record?
    This is to be used for incidents of a very sensitive nature.
    You must enter a value in this field
1. Details of person reporting the incident
1. Incident Date
2. - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Time (hh:mm)
    Please apply the 24 hour clock.
    You must enter a value in this field
1. Locations
  
  Please begin typing the name of the ward, clinical area or other location where the incident occurred. A list of appropriate options to choose from will appear as you type.
2. - Location
    You must enter a value in this field
1. Services
  
  Please begin typing the name of the service where the incident occurred.
  A list of appropriate options to choose from will appear as you type.
2. - Service
    You must enter a value in this field
  - Directorate
    Please complete this.
    You must enter a value in this field
1. Incident Coding
  
  Additional sections may be revealed depending on the incident that is being reported.
  
  Please select the most appropriate Type, Category and Subcategory for the incident.
  For example - Staffing issues you would record:
  Incident affecting - Staff
  Incident Type - Exposure to Environmental Hazards
  Incident Category - Workplace stressors and demands
  Incident Subcategory - Staffing levels
  
  If possible don't select other unless the incident does not fit under any other coding.
1. Incident Details
2. - Description
    Use the following as prompts to help you fill in this section:
    
    • In one sentence, give a summary of what happened and the outcome - e.g. Patient fell while transferring to chair, resulting in no injury or This is a record relating to: A FGM incident or Greatix report or Freedom to Speak up report.
    
    Do not put any names into this field (as this will be a breach of confidentiality).
    You must enter a value in this field
  - Action taken
    Give details of the steps taken to deal with the incident.
    
    Do not put any names into this field (as this will be a breach of confidentiality).
    You must enter a value in this field
  - The consultant or clinician's care that the patient is under.
    You must enter a value in this field
1. Incident Harm and Severity
1. Duty of Candour
  
  Please complete if the process has been started.
1. Clinical Incidents
1. DOLS Details
1. Information Governance
1. Needlestick Injuries
1. Patient Falls
1. PPH Questions
1. Pressure Ulcers
1. Medications
  
  Please can you complete name of medication - by search on 3 or 4 characters. If you don't know because it is nutrition or alike put in Unkn and the search - then unknown should come up.
  
  Please also can you complete stage and medication error. That would be really helpful.
1. Medical Device
  
  Please select 'Brand of name' to be able to search for a peice of equipment.
1. Cardiac Arrests
1. Actual/Suspected Domestic Abuse
1. Freedom to Speak Up
1. Greatix
1. FGM
1. Additional Information
2. - Were there any witnesses to the incident?
    You must enter a value in this field
  - Was any employee 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
  - Are there any documents to be attached to this record?
    You must enter a value in this field
1. People Affected
1. Witnesses
1. Employees
1. Contacts
1. Documents
1. Investigating Manager
2. - Investigating manager
    This is the manager responsible for the physical area where the incident occurred.
    
    This may not necessarily be your line manager.
    You must enter a value in this field
1. Openness and Transparency
2. - Were the members of staff involved in the incident involved in informing the patient/appropriate person?
    You must enter a value in this field
  - Please provide details of staff members who informed the patient/appropriate person.
    You must enter a value in this field
  - Was an apology provided to the patient/appropriate person?
    You must enter a value in this field
  - Was a truthful account of the facts known at the time shared with the patient/appropriate person?
    You must enter a value in this field
  - Was the patient/appropriate person advised about next investigative steps to be undertaken?
    You must enter a value in this field
  - Was a written memo of the initial disclosure securely recorded?
    You must enter a value in this field
  - Was a copy of this memo provided to the patient/appropriate person?
    You must enter a value in this field
  - When was this memo provided to the patient/appropriate person? (dd/mm/yyyy)
    You must enter a value in this field
  - Following a thorough investigation were details related to personnel or system insufficiencies/failures discussed
    You must enter a value in this field
  - Were details of personnel or system insufficiencies/failures and/or errors included in a report?
    You must enter a value in this field
  - Following investigation was a detailed written investigation report securely recorded?
    You must enter a value in this field
  - Was a copy of this detailed report provided in full to the patient/appropriate person?
    You must enter a value in this field
  - Were unsuccessful attempts to contact the patient/appropriate person recorded?
    You must enter a value in this field
  - Were support services offered to the patient/appropriate person affected by the incident?
    You must enter a value in this field
  - Did the patient/appropriate person accept the support services offered?
    You must enter a value in this field
  - What was the nature of support services provided?
    You must enter a value in this field
  - Were follow-up discussions offered to the patient/appropriate person?
    You must enter a value in this field

Incidents

Croydon Health Services Incident Reporting Form