NIRF-01 Form PDF Details

In today's fast-paced healthcare environment, the ability to respond effectively to incidents is critical for maintaining safety and quality standards. The National Incident Report Form (NIRF), specifically the HC NIRF 01 – V11, serves as a fundamental tool in this process. Issued on 20/03/2020, the form is designed to capture detailed information about incidents that could have or did lead to unintended and/or unnecessary harm. It encompasses a wide range of categories, including the general details of the incident, the people affected, the outcome at the time of the incident, and the type of injury, among others. This comprehensive approach ensures all aspects of the incident are documented, from service user details to external contractor information, outcomes, and types of injuries or diseases diagnosed as a result. This structured framework not only aids in the immediate response and management of incidents but also in the long-term analysis and strategy development to prevent future occurrences. By capturing specifics such as the location, involved parties, and the nature of the harm or potential harm, healthcare organizations can better understand incident patterns, improve safety protocols, and enhance overall care quality.

QuestionAnswer
Form Name NIRF-01 Form
Form Length 6 pages
Fillable? Yes
Fillable fields 112
Avg. time to fill out 18 min
Other names SCE 14 baseline fillable, IE incident form, NIRF-01 person, how to fill out a NIMS NIRF01 form

Form Preview Example

NATIONAL INCIDENT REPORT FORM (NIRF)

HC NIRF 01 – V11NIRF - 01 PERSON

Date issued: 20/03/2020

NIMS record Number:

Incident: An event or circumstance which could have, or did lead to unintended and / or unnecessary harm. Please complete this form to the best of your knowledge at the time of reporting the incident.

SECTION A: GENERAL INCIDENT DETAILS

Date of incident

Time of incidentUSE 24

HOUR CLOCK

Location E.g. Hospital, Health Centre, Residential Centre etc.

Specific Location

E.g. Ward, Clients home etc.

Offsite?

 

 

 

SECTION B: PERSON AFFECTED DETAILS

First name

Surname

Date of birth

FemaleMale

Description of incident:

Division (tick one only )

Acute Hospital

Social Care

Health and Wellbeing

Primary Care

Mental Health

Ambulance Service

National Corporate Services (staff only)

Who was involved…? (tick one only )

Service user – (Resident/Patient/Client) Go to section C

Staff member – Go to section D

Agency / Panel staff – Go to section D

Member of public-Proceed to section F

Volunteer – Go to section D

External Contractor – Go to section E

Student – Go to section D

SECTION C: SERVICE USER DETAILS ONLY

SECTION D: STAFF MEMBER / AGENCY / PANEL STAFF / STUDENT / VOLUNTEER DETAILS ONLY

Healthcare Record No

Lead Clinician

This incident involved… (tick one only )

Neonatal Specialties

Paediatric Specialties

Adolescent Specialties

Adult Specialties

Older Person Specialties

Category of person

Employee no.

Date absence commenced (if known)

Date returned to work

(if known)

Work days lost

Note: For employee incidents reportable to HSA that result in an absence from duty for more than three consecutive days, excluding the day of the accident, the date absence commenced and the date employee returned to work should be recorded on the NIMS

 

E.g. Antenatal, Audiology,

Incident Occurred under

Radiotherapy, Intellectual Disability,

(Service / Specialty)

Psychology

 

 

 

SECTION E: EXTERNAL CONTRACTOR DETAILS ONLY

Company Name

Company no.

Page 1 of 6

SECTION F: WHAT WAS THE OUTCOME AT THE TIME OF THE INCIDENT?

 

Outcome

 

Body Part Affected

 

 

Near Miss e.g. Nearly given wrong drug

 

 

 

 

 

 

 

 

 

No Injury e.g. Wrong drug given but no harm

Category 3

 

 

 

occurred

 

 

 

 

 

 

 

 

Injury not requiring first aid

 

 

 

 

 

 

 

 

 

Injury or illness, requiring first aid

 

 

 

 

Injury requiring medical treatment

Category 2

 

 

 

Long-term disability / Incapacity (incl. psychosocial)

 

 

 

 

 

 

 

 

 

Permanent Incapacity (incl. Psychosocial)

Category 1

E.g. Arm, Spine, Lung, Other Physiological

 

 

Death

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION G: TYPE OF INJURY (tick one only )

 

Apgar score <5@ 1 min &/or;

HIE Grade 2 - Hypoxic Ischaemic

Nerve Injury - face

 

7@5mins &/or pH ≤ 7.0

Encephalopathy

Other unexpected deterioration

 

Aspiration

HIE Grade 3 - Hypoxic Ischaemic

Stillbirth

 

Cerebral irritability / neonatal

Encephalopathy

Sub-galeal / sub-aponeurotic

Birth Specific Injury

seizure

Hypoglycaemia - severe

haemorrhage

(Baby)

HIE - Hypoxic Ischaemic

Kernicterus

Unknown

 

Encephalopathy with

Neonatal death

Other

 

Hypoglycaemia

Nerve Injury - brachial plexus (incl.

 

 

 

 

 

 

 

HIE Grade 1 - Hypoxic Ischaemic

Erbs Palsy)

 

 

 

 

 

 

 

Encephalopathy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Death

Perineal tear

Unknown

Birth Specific Injury

Hysterectomy (Perinatal)

Post-Partum Haemorrhage

Uterine rupture

(Mother)

Incontinence (faecal)

Rhesus iso-immunisation

Other

 

Incontinence (urinary)

Incontinence (faecal & urinary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Excessive Bleeding

Febrile non-haemolytic transfusion

Non-immunological haemolysis

Blood Specific Injury

Fainting

reaction

Other

 

Immunological haemolysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asbestosis

Hepatitis

Unknown

Diagnosed Disease

Cancer

HIV

Dermatitis

Acute Radiation Syndrome

Brucellosis

TB

Disorder or Cond.

Narcolepsy/Cateplexy

Legionnaires

Pleural Plaques

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

Clostridium Difficle

Hepatitis

VRE

Diagnosed Infection

COVID-19

MRSA

VRSA

 

CPE

Norovirus

Other

 

ESBL

Unknown

 

 

 

 

 

 

 

Allergic Reaction (incl. anaphylaxis)

Cut / Laceration / Graze / scratch

Malaise / Nausea

 

Brain Injury / Concussion

Death

Nerve injury / Loss of Function

 

Burn / scald / corrosion

Dental injury &/or loss

Puncture / bite

General Injuries

Choking / asphyxia

Deterioration

Rash / irritation

 

Circulatory / volume depletion

Haemorrhage

Unknown

 

Circulatory / volume overload

Blister

Other

 

Pain/Discomfort

 

 

 

 

 

 

 

Hearing / Sight Injury

Hearing Impairment / loss

Tinnitus

Other

Sight Impairment / loss

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Misdiagnosis

Cancer

Infection

Other

Fracture

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amputation

Fracture

Swelling / Inflammation

 

Bruising

Repetitive Strain Injury (RSI)

Unknown

 

Crushing

Slipped / Prolapsed Disc

Whiplash

Musculoskeletal

Dental Fracture / Tooth loss

Sprain / Strain

Other

Dislocation

Soft tissue injury

 

 

 

 

 

 

/ Soft Tissue

 

 

 

 

 

 

P. Ulcer Stage 1: Intact skin with non-blanchable redness over bony prominence

 

 

P. Ulcer Stage 2: Part thickness dermis loss: blister/open ulcer/no slough

 

 

 

 

 

 

 

P. Ulcer Stage 3: Full thickness tissue loss: +/- visible subcutaneous fat

 

 

 

 

 

 

 

P. Ulcer Stage 4: Full thickness tissue loss/necrosis: exposed bone/tendon/muscle

 

Additional / Further Surgery

Loss of Wages / Income /

Unknown

Personal Loss

Limb Deformity

Business

Organ Retention

 

Defamation of Character

Loss of Consortium

Other

 

 

 

 

 

 

 

 

 

Damage to organ / body part

Loss of organ / body part

Unexpected complication /

Surgery Specific

Dental Damage / Loss

Nerve injury / Loss of

deterioration

Injury

Foreign body left in situ

Function

 

 

 

 

 

 

 

Unknown

Inadequate anaesthesia

Other

 

 

 

 

 

 

Traumatic/Emotional

Anxiety / Trauma

Stress

Worried Well

PTSD

Unknown

Other

 

 

 

 

 

 

 

 

 

 

HC NIRF-01

Page 2 of 6

SECTION H WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, 3 & 4)

 

 

 

Step 1.

Step 2.

 

 

Step 3.

 

Step 4.

 

 

 

 

 

 

 

 

 

 

 

Caesarean Section

 

Communication / Consent

Adverse Effect

 

 

 

 

 

 

 

 

 

 

 

 

 

(Elective)

 

 

Failure / Malfunction

 

 

 

 

 

 

Diagnosis / Assessment

 

 

 

 

 

 

 

 

 

 

 

 

 

Caesarean Section

 

 

Foreign Body left in Situ

 

 

 

 

 

 

Documentation / Records

 

 

 

 

 

 

 

 

 

 

 

 

 

(Emergency)

 

 

Inappropriate for Task / Wrong device

 

 

 

 

 

 

Equipment

 

 

 

 

 

Instrumental Delivery

 

 

Incomplete / Inadequate

 

 

 

 

Birth Specific

 

General Care / Management

 

 

 

 

(Forceps)

 

 

Lack of Availability

 

 

 

 

 

Procedure / Treatment /

 

 

 

 

 

 

 

 

 

 

 

 

Procedures

Instrumental Delivery

 

 

Not performed when indicated / Delay

 

 

 

 

 

Intervention

 

 

 

 

 

(Vacuum)

 

 

Pre Existing Medical Condition

 

 

 

 

 

 

Screening / Prevention

 

 

 

 

 

 

 

 

 

 

 

 

 

Instrumental Delivery

 

 

Shoulder Dystocia

 

 

 

 

 

 

Specimens / Results

 

 

 

 

 

 

 

 

 

 

 

 

 

(Multiple Instruments)

 

 

Unavailable / Mislabelled / Lost

 

 

 

 

 

 

Tests / Investigations

 

 

 

 

 

 

 

 

 

 

 

 

 

Non Instrumental

 

 

Wrong Body Part / Site / Side

 

 

 

 

 

 

Unknown

 

 

 

 

 

Delivery

 

 

Wrong Patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

Clinical

Invasive

 

 

Wrong Process / Treatment / Procedure

 

 

 

 

 

 

 

 

 

 

 

 

Procedures

Non Invasive

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ROUTE OF ADMINISTRATION

 

 

 

 

Adverse Drug Reaction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral

 

Administration

Contra-indicated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intravenous

 

Monitoring

Drug Interaction

 

 

 

 

 

Sub Cutaneous

 

 

Ordering / Supply / Transport

Failure / Malfunction of equipment

 

 

 

 

 

 

Preparation / Dispensing

 

 

 

 

 

Intra Muscular

 

 

Incomplete / Inadequate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Pharmacy)

 

 

 

 

 

 

 

 

Topical

 

 

Not preformed when indicated /

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescribing

delayed

 

 

 

 

 

Rectal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication

 

Reconciliation

Omitted/Delayed Dose

 

 

 

 

Inhalation

 

 

 

 

 

 

 

 

Storage

Wrong Dose / Strength

 

 

 

 

 

 

 

 

 

 

 

 

 

Other / Unknown

 

 

 

 

Wrong Drug

 

 

 

 

 

WHAT MEDICATION WAS INVOLVED?

 

 

 

Wrong Formulation / Route

 

 

Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wrong Frequency

 

 

 

 

MEDICATION ONE

 

 

 

Wrong Label / Instructions

 

 

Clinical

 

 

 

 

 

 

 

 

Wrong Patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATION TWO

 

 

 

Wrong Quantity / Duration

 

 

 

 

 

Parenteral

Communication / Consent

Adverse Effect

 

 

 

 

 

Enteral

Prescribing / Requesting

Incomplete / Inadequate

 

 

 

 

Nutrition

Special Diet

Preparation / Dispensing

Not performed when indicated / Delay

 

 

 

 

 

General Diet

Administration

Wrong Consistency

 

 

 

 

 

Other

Storage

Wrong Diet / Wrong Blood Product

 

 

 

 

 

Whole Blood

Documentation / Records

Wrong Process / Treatment / Procedure

 

 

 

 

 

Equipment

Wrong Patient

 

 

 

 

 

Red Cells

 

 

 

 

Blood / Blood

Supply / Ordering / Transport

Lack of Availability

 

 

 

 

Platelet (Apheresis)

 

 

 

 

Product

Presentation / Packaging

Wrong dispensing label / instructions

 

 

 

 

Platelets (Pooled)

 

 

 

 

 

Transfusing blood

Inappropriate for task / Wrong device

 

 

 

 

 

Other

 

 

 

 

 

Other

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnostic Exposure > intended

 

 

 

 

 

 

 

 

Checking Patient ID

X-ray Over Exposure

Above Notifiable levels

 

 

 

 

Diagnostic

Wrong body part / side

Below Notifiable levels

 

 

 

 

procedure

 

 

 

 

Dose to comforters / carers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radiology (DR)

 

 

 

 

 

 

 

 

 

 

Clinical Details on

Wrong Patient

<1mSv

 

 

 

 

& Nuclear

Referral

 

 

 

 

Inadvertent dose to foetus

>1mSv

 

 

 

 

Medicine (NM)

Communication /

 

 

 

 

Total dose or Volume Variation

<10%

 

 

 

 

 

 

 

Consent

 

 

 

 

 

 

 

Dose (NM) or Volume Variation

10-20%

 

 

 

 

 

 

Documentation /

 

 

 

 

 

 

(1 fraction)

>20%

 

 

 

 

 

 

 

Records

 

 

 

 

 

 

 

Wrong Drug

 

 

 

 

 

 

 

 

Equipment

 

 

 

 

 

 

 

 

Wrong Dose

 

 

 

 

 

 

 

 

Performing procedure

 

 

 

 

 

 

 

 

Wrong Process / Treatment /

 

 

 

 

 

 

 

Radiotherapy

Pregnancy Status

 

 

 

 

 

 

 

Intervention

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

Failure / Malfunction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inadvertent deterministic effects

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposure to Bite (Human)

 

 

 

 

 

 

 

 

 

 

 

Exposure to Bite (Insect / Animal)

 

 

Hazards

 

Acquired

 

 

 

 

 

 

Exposure to Bodily Fluids

 

 

 

Bacteria

 

 

 

Exposure to Ingestion/Food/Water

 

 

 

 

Biological

 

 

 

 

 

 

 

Fungus / Mould

 

 

 

Exposure to Needle Stick

 

 

 

 

Hazards /

Please specify, if known:

 

 

 

 

Prion

Exposure to Skin Contact

 

 

 

 

 

 

 

 

 

 

Bio

 

Infections

Virus

 

 

 

Inhalation/Airborne

 

 

 

Organism Unknown

 

 

 

Equipment, Implements, Facilities,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.g. COVID-19; MRSA etc.

Sharps (Non Needle)

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

Other

 

HC NIRF-01

Page 3 of 6

SECTION H CNTD: WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2 & 3)

Behavioural Hazards

Physical Hazards

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 1.

 

 

Step 2.

 

Step 3.

 

 

 

 

 

 

 

 

Absconsion / Missing

 

 

 

 

 

 

 

 

Attempted Suicide

 

 

 

 

 

 

 

 

Banging Self Against Walls/Furniture/Surfaces

 

 

 

 

 

 

 

 

Hitting Body/Slap/Punch Self incl. Scratching &

 

 

 

 

 

 

 

 

Picking

 

 

Self-Injurious

 

Intentional

Inappropriate Eating

 

 

Behaviour

 

Unintentional

Inappropriate Touching

 

 

 

 

 

 

 

 

Self-Harm

 

 

 

 

 

 

 

 

Stripping Clothes in Public Area

 

 

 

 

 

 

 

 

Suicide

 

 

 

 

 

 

 

 

Throwing objects

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aggressive towards inanimate object

 

 

Violence, Harassment

 

 

 

 

 

Discrimination/Prejudice/Racial

 

 

and Aggression

 

 

 

 

 

Intimidation / Threat

 

 

 

 

 

 

 

Neglect

 

 

 

 

 

 

 

 

 

 

 

 

By a Family Member / Relative

Non-Compliant / Obstructive / Rude

 

 

 

 

 

 

 

By a Member of the Public

Physical Assault / Abuse

 

 

Child Abuse

 

By a Peer / Student

Physical Harassment

 

 

 

 

By a Prisoner

Sexual Assault / Abuse

 

 

 

 

By a Service User

Sexual Harassment

 

 

 

 

 

 

 

By a Staff Member

Unintentional Aggressive Behaviour

 

 

 

 

 

 

 

 

Bullying

 

 

Adult Abuse

 

 

 

 

 

Verbal Assault / Abuse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verbal Harassment

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

Pre Existing Medical Condition

 

 

 

 

 

 

 

 

Inadequate supervision gen health / post op

 

 

 

 

From Height

Obstruction / protruding object

 

 

 

 

Surface contaminants

 

 

 

 

From Equipment / Furniture

 

 

 

 

Rough terrain / irregular surface

 

 

 

 

Same Level / Ground

 

 

Slip / Trip / Fall

 

Inappropriate equipment use

 

 

 

On Stairs

 

 

 

 

Failure / malfunction of equipment

 

 

 

 

On Steps

 

 

 

 

Horseplay

 

 

 

 

Other

 

 

 

 

Physical training / sport

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weather Condition

 

 

 

 

 

 

 

 

Inadequate Lighting / design

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Object / Tools (Non Sharps)

 

 

 

 

 

 

Non Mechanical

 

Sharps (Non Needle)

Human Use / Error

 

 

 

 

 

 

 

 

 

 

(Incl. Person / Animal)

 

Other

Obstruction / Protruding Object

 

 

 

 

Person

Physical Training / Sport

 

 

 

 

 

 

 

 

 

 

Ergonomics

 

Manual Handling

Defective Equipment

 

 

 

Other

Unsafe / Inappropriate system

 

 

(Incl. manual / people

 

 

 

 

Patient Handling

Unknown

 

 

handling)

 

 

 

 

Restraint / Intervention

Task

 

 

 

 

 

 

 

 

Catering equipment

Load

 

 

 

 

 

 

 

 

 

 

Mechanical

 

Door / Gate / Barrier

Working Environment

 

 

 

 

 

 

 

 

 

 

Healthcare Equipment

Individual Capability

 

 

 

 

 

 

Components

 

 

 

 

 

 

 

 

Lifting Equipment / Accessories

Other

 

 

 

 

 

 

 

 

 

 

 

 

Office / Business equipment

 

 

 

 

 

 

Temperature

 

Hot

Liquid / Food / Steam

 

 

 

Equipment / Utensils

 

 

(Excluding Fire)

 

Cold

 

 

 

Atmosphere / Environment

 

 

 

 

 

 

 

 

 

 

Fire

 

 

 

 

 

Defective Equipment

 

 

 

 

 

 

 

Human Use / Error

 

 

Vibration

 

 

 

 

 

 

 

 

Please Specify

Unknown

 

 

 

 

 

 

Electrical

 

 

 

 

 

Unsafe System

 

 

Noise

 

 

 

 

 

Explosion

 

 

 

 

 

 

 

Exposure

 

 

Radiation

 

 

 

 

 

 

 

 

 

 

 

 

Electrical Wiring / installation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HC NIRF-01

Page 4 of 6

SECTION H CNTD: WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, & 3)

 

 

Step 1.

 

Step 2.

 

 

Step 3.

 

 

 

 

 

 

 

 

 

 

Animal Remedy

 

Insecticide

 

 

 

 

 

Arsenic

 

Lead

 

 

 

 

Acid / Alkaline

Asbestos

 

Metallic Dust

 

 

 

 

Bleach

 

Motor / Gear / Hydraulic Oil

 

 

 

 

 

 

 

 

 

 

Agri Chemicals

Cadmium

 

Natural Gas

 

 

 

Hazards

Gas

Carbon Dioxide

 

Organic Dust

 

 

 

Carbon Monoxide

 

Paint / Paint Product

 

 

 

Other Chemical

 

 

 

 

Chemical Fertilizer

 

Petrol

 

 

 

Products

 

Lack of Supervision

 

 

Crystalline Silica

 

Polish

 

 

 

Unknown

 

 

Chemical

Particulates

Detergent

 

Radon

 

 

 

Human / User Error

 

 

 

Diesel / Kerosene

 

Rodenticide

 

 

Petroleum / Synthetic

 

Unsafe System

 

 

Disinfectant

 

Soap

 

 

Oil Based Products

 

 

 

 

Drain / Oven Cleaner

 

Sodium Hydroxide

 

 

 

Sanitation / Cleaning

 

 

 

 

 

Drugs

 

Solvents

 

 

 

 

Chemicals

 

 

 

 

 

Fungicide

 

Spent / Used Oil Product

 

 

 

 

 

 

 

 

 

 

Toxic Metals

Glue / Adhesive

 

Sulphuric Acid

 

 

 

 

 

Grease

 

Wrong Patient

 

 

 

 

 

Herbicide

 

Other

 

 

 

 

 

Hydrochloric Acid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I: IMMEDIATE ACTIONS TAKEN

SECTION J: REPORTED BY: person who discovers the incident and unless

otherwise stated within the organization, this person is responsible for completing the NIRF.

First name

 

 

Surname

 

 

Date notified

 

 

Category of person

E.g. Nurse, Catering Staff, Cleaner

 

 

 

 

Local system

 

 

reference no.

 

 

Reporter Signature

 

 

SECTION K: WITNESS DETAILS (Name, Contact No. etc.)

Date

Contact Details

HC NIRF-01

Page 5 of 6

SECTION L: TO BE COMPLETED BY LINE/DEPARTMENT MANAGER

Has open disclosure happened? (tick one only )

Yes

No

If No, please specify:

CATEGORY 1 INCIDENTS ONLY

SAO Name [Block Capitals]:

 

Date notified to SAO:

SAO Email and Contact Details:

Is there a requirement to report this incident to any external

 

 

 

 

regulators/agencies/insurers (other than the State Claims Agency)?

Yes

No

If Yes: Name regulator(s)/agency(ies) reported/notified to:

 

 

 

Date Notified:

1

 

 

 

 

 

 

2

 

 

 

 

 

 

3

 

 

 

 

 

 

Line/Department Manager name [Block Capitals]:

 

 

 

Title:

 

Signature of Line/Department Manager:

 

 

 

Date:

SECTION M: TO BE COMPLETED BY QUALITY AND PATIENT SAFETY OFFICE

Is this incident a Serious Reportable Event (SRE)? (tick one only )

Yes

No

QPS Advisor Name [Block Capitals]:

 

 

 

 

Signature of QPS Advisor:

 

 

Date:

 

 

 

 

 

HC NIRF-01

Page 6 of 6

How to Edit NIRF-01 Form Online for Free

This step-by-step process guarantees a thorough approach to reporting incidents, crucial for improving healthcare safety.

1. Fill in General Incident Details

Begin by providing the date and time of the incident using a 24-hour clock format. Specify the general location, such as the hospital or health center, and the specific location, like the ward or patient's home, where the incident occurred.

2. Person Affected Details

Identify the person affected by the incident. Enter their first name, surname, and date of birth. Specify the gender and division they belong to — such as Acute Hospital, Social Care, etc. Indicate the category of the person involved, whether a service user, staff member, volunteer, or external contractor, directing to the appropriate subsequent section based on their role.

3. Describe the Incident

Provide a detailed description of the incident. This should include what happened, the sequence of events, and any immediate factors contributing to the incident.

4. The Outcome at the Time of the Incident

Record the immediate outcomes of the incident. This includes whether it was a near miss, resulted in no injury, required first aid, or led to more severe consequences such as long-term disability or death. Specify the body part affected if there was an injury.

5. Specify the Type of Injury

If applicable, detail the type of injury sustained. Options include specific injuries related to birth, blood-specific injuries, diagnosed diseases, and general injuries.

6. Identify the Type of Hazard

Indicate what type of hazard led to the incident, whether clinical care, medication issues, equipment failure, or environmental conditions.

7. Report Immediate Actions Taken

Note any immediate actions that were taken in response to the incident. This could include medical treatment provided, safety measures implemented, or other emergency responses.

8. Reporter and Witness Details

The person who identifies the incident should fill out their details and those of any witnesses. This includes names, contact information, and the role of the person reporting the incident.

9. Management Review

The line or department manager reviews the completed form, verifies open disclosure, and indicates whether the incident needs to be reported to external regulators or agencies.

10. Quality and Patient Safety Office Review

Finally, the Quality and Patient Safety Office must determine if the incident qualifies as a Serious Reportable Event (SRE) and complete its form section.