Homecare Medicines Service Complaint/Incident Report Form



Total number of pages in this report FORMTEXT ?????Receipting homecare organisation name: FORMTEXT ?????Receipting homecare organisation complaint/incident reference number: FORMTEXT ?????Date incident reported: FORMTEXT ?????Written response required: FORMCHECKBOX Yes FORMCHECKBOX NoAbout the patient and reporterPatient detailsPatient forename: FORMTEXT ?????NHS number: FORMTEXT ?????Patient surname: FORMTEXT ?????Hospital number: FORMTEXT ?????Date of birth: FORMTEXT ?????Homecare provider patient number: FORMTEXT ?????Ethnicity:Choose an item.Gender: FORMCHECKBOX Male FORMCHECKBOX FemaleAddress: FORMTEXT ?????Country: FORMCHECKBOX England FORMCHECKBOX Northern Ireland FORMCHECKBOX Scotland FORMCHECKBOX WalesCarer’s Name: FORMTEXT ?????Therapy: FORMTEXT ?????Diagnosis: FORMTEXT ?????Clinical Referring Centre: FORMTEXT ?????Complaint/incident reporter detailsName of reporter: FORMTEXT ?????Reporter type:Choose an item.Telephone: FORMTEXT ?????Email: FORMTEXT ?????Address: FORMTEXT ?????Complaint/incident recipient detailsName of person completing form: FORMTEXT ?????Position of person completing form: FORMTEXT ?????Contact telephone: FORMTEXT ?????About the complaint/incidentDate complaint/incident occurred: FORMTEXT ?????Time complaint/incident occurred: FORMTEXT ?????Location incident occurred: FORMCHECKBOX Home setting FORMCHECKBOX Work FORMCHECKBOX School FORMCHECKBOX Care home FORMCHECKBOX Nursing home FORMCHECKBOX Hospital FORMCHECKBOX Other: specify FORMTEXT ?????About the complaint/incident (continued)Was the patient actually harmed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t Know If yes, what was the harm and to what part of the body? FORMTEXT ?????In your opinion, was this event preventable? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t knowDescribe what happened: (Do not use any personal identifiable data here. Instead for example say the patient, the hospital nurse or the customer service agent) FORMTEXT ????? FORMTEXT ?????Personal identifiable information related to the complaint/incident: (E.g. Hospital nurse = Jane DoeCustomer service agent = Joe Bloggs) FORMTEXT ????? FORMTEXT ?????Immediate corrective and preventative actions taken: FORMTEXT ?????Relevant medical history: FORMTEXT ?????Where available, reference any supporting evidence to the description provided: FORMTEXT ?????For medicinal products - does the reporter agree to be contacted by the manufacturer if they want more information? FORMCHECKBOX Yes FORMCHECKBOX No Does the reporter require a written response? FORMCHECKBOX Yes FORMCHECKBOX No Categories for complaints and incidents (tick all that apply)Initial categorisation: FORMCHECKBOX Patient safety incident including Duty of Candour FORMCHECKBOX Adverse drug reaction and/or event FORMCHECKBOX Faulty medicinal product/device FORMCHECKBOX Safeguarding incident FORMCHECKBOX Information governance incident FORMCHECKBOX Non-conformance FORMCHECKBOX Complaint – informal – no written response required FORMCHECKBOX Complaint – formal – written response required FORMCHECKBOX Not reportable – any incident downgraded following triage/investigationAbout the medicine(s) involved in a complaint or incidentMedicine 1Approved medicine name: FORMTEXT ?????Proprietary medicine name: FORMTEXT ?????Manufacturer: FORMTEXT ?????Form: FORMTEXT ?????Strength: FORMTEXT ?????Dose frequency: FORMTEXT ?????Route: FORMTEXT ?????Batch number: FORMTEXT ?????Expiry date: FORMTEXT ?????Is the medicine available for inspection? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where is the medicine now? FORMTEXT ?????In the reporter’s opinion how likely is this event due to the use of this medicine? FORMCHECKBOX Very Unlikely FORMCHECKBOX Unlikely FORMCHECKBOX Likely FORMCHECKBOX Very LikelyHas this been confirmed by a healthcare professional (HCP)? FORMCHECKBOX Yes FORMCHECKBOX No If Yes name of HCP FORMTEXT ?????Details of other medicines being taken at the same time: FORMTEXT ?????Other relevant information about the medicine: FORMTEXT ?????Medicine 2Approved medicine name: FORMTEXT ?????Proprietary medicine name: FORMTEXT ?????Manufacturer: FORMTEXT ?????Form: FORMTEXT ?????Strength: FORMTEXT ?????Dose frequency: FORMTEXT ?????Route: FORMTEXT ?????Batch number: FORMTEXT ?????Expiry date: FORMTEXT ?????Is the product available for inspection? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where is the medicine now? FORMTEXT ?????In the reporter’s opinion how likely is this event due to the use of this medicine? FORMCHECKBOX Very Unlikely FORMCHECKBOX Likely FORMCHECKBOX Unlikely FORMCHECKBOX Very LikelyHas this been confirmed by a healthcare professional (HCP)? FORMCHECKBOX Yes FORMCHECKBOX No If Yes name of HCP FORMTEXT ?????Details of other medicines being taken at the same time: FORMTEXT ?????Other relevant information about the medicine: FORMTEXT ?????If more than two medicines are to be reported, attach a separate sheet to this report form and reference it in the supporting documents field aboveAbout the medical device(s) involved in a complaint or incidentDevice 1Name of medical device: FORMTEXT ?????Model: FORMTEXT ?????Manufacturer: FORMTEXT ?????Catalogue number: FORMTEXT ?????Serial number: FORMTEXT ?????Supplier: FORMTEXT ?????Batch number: FORMTEXT ?????Expiry date: FORMTEXT ?????Date of manufacture: FORMTEXT ?????Is the device available for inspection? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where is the device now? FORMTEXT ?????Other relevant information about the device: FORMTEXT ?????Device 2Name of Medical Device: FORMTEXT ?????Model: FORMTEXT ?????Manufacturer: FORMTEXT ?????Catalogue Number: FORMTEXT ?????Serial number: FORMTEXT ?????Supplier: FORMTEXT ?????Batch number: FORMTEXT ?????Expiry date: FORMTEXT ?????Date of manufacture: FORMTEXT ?????Is the device available for inspection? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, where is the device now? FORMTEXT ?????Other relevant information about the device: FORMTEXT ?????If more than two devices are to be reported, attach a separate sheet to this report form and reference it in the supporting documents field above ................
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