Homecare Medicines Service Complaint/Incident Report ...



To help us investigate your complaint/incident, please complete as much of the form as you can. If you need help completing the form contact patient services for assistance. If you cannot completed a section please put don’t know or not applicable. You do not need to use this form to report an incident or complaint - talk to your clinic or patient services contact for further advice.About YouPatient detailsPatient forename: FORMTEXT ?????NHS number: FORMTEXT ?????Patient surname: FORMTEXT ?????Hospital number: FORMTEXT ?????Date of birth: FORMTEXT ?????Carer’s name: FORMTEXT ?????Ethnicity: Choose an item. Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Don’t know Address: FORMTEXT ?????Country: FORMCHECKBOX England FORMCHECKBOX Northern Ireland FORMCHECKBOX Scotland FORMCHECKBOX WalesHomecare provider: FORMTEXT ?????Medicines delivered by homecare provider: FORMTEXT ?????Diagnosis treated using medicines delivered by homecare provider: FORMTEXT ?????Hospital prescribing medicines delivered by homecare provider: FORMTEXT ?????Complaint/incident reporter detailsRelationship to patient / Reporter type: FORMTEXT ?????Choose an item. FORMTEXT ?????Name of reporter/person completing form: FORMTEXT ?????Telephone: FORMTEXT ?????Email: FORMTEXT ?????Address: FORMTEXT ?????About the complaint or 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 ?????Date reported: FORMTEXT ?????Time reported: FORMTEXT ?????Was the patient actually harmed? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t knowIf 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 ?????Personal identifiable information about the complaint/incident: (E.g. Hospital nurse = Jane DoeCustomer service agent = Joe Bloggs) FORMTEXT ?????Where available, reference any evidence supporting the description of what happened: FORMTEXT ?????Immediate actions taken: FORMTEXT ?????Relevant medical history: FORMTEXT ?????For medical products - do you agree to be contacted by the manufacturer if they want more information? FORMCHECKBOX Yes FORMCHECKBOX NoWe will talk to you to explain what happened and what we have done to stop similar incidents happening again in future. Do you also require a written response? FORMCHECKBOX Yes FORMCHECKBOX NoAbout the medicine(s) Where you have described a complaint or incident related to a medicine, please give details of the medicine(s) hereMedicine 1Approved medicine name (drug name): FORMTEXT ?????Proprietary medicine name (brand): FORMTEXT ?????Medicine manufacturer: FORMTEXT ?????Form: (e.g. table, pre-filled syringe) FORMTEXT ?????Strength: FORMTEXT ?????Dose frequency: FORMTEXT ?????Route: (e.g. oral, s.c. injection) 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 your opinion how likely is this event due to the use of this medicine? FORMCHECKBOX Very Unlikely FORMCHECKBOX Unlikely FORMCHECKBOX Likely FORMCHECKBOX Very LikelyPlease tell us about other medicines being taken at the same time: FORMTEXT ?????Medicine 2Approved medicine name (drug name): FORMTEXT ?????Proprietary medicine name (brand): FORMTEXT ?????Medicine manufacturer: FORMTEXT ?????Form: (e.g. table, pre-filled syringe) FORMTEXT ?????Strength: FORMTEXT ?????Dose frequency: FORMTEXT ?????Route: (e.g. oral, s.c. injection) 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 your opinion how likely is this event due to the use of this medicine? FORMCHECKBOX Very Unlikely FORMCHECKBOX Unlikely FORMCHECKBOX Likely FORMCHECKBOX Very LikelyPlease tell us about other medicines being taken at the same time: 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) Where you have described a complaint or incident related to a medical device, please give details of the device(s) hereDevice 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 ?????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 ?????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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