Are you considering filing a Nirf 01 form with the IRS? Well, understanding the process of filing and properly managing your taxes can be a confusing and arduous task. Fortunately, however, it doesn't have to be. As long as you are familiar with the information requested on form nirf01, knowing when it needs to be filed and what documentation is necessary to complete it correctly - this task can become much simpler. Read along in this blog post to discover important details about the nirf01 form so that you can make sure all your tax obligations are met without any hitch!
| Question | Answer |
|---|---|
| Form Name | Nirf 01 Form |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | sce 14 baseline fillable, ie incident form, nirf 01 person, how to fill out a nims nirf01 form |
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? |
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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
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
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E.g. Antenatal, Audiology, |
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Incident Occurred under |
Radiotherapy, Intellectual Disability, |
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(Service / Specialty) |
Psychology |
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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?
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Outcome |
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Body Part Affected |
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Near Miss e.g. Nearly given wrong drug |
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No Injury e.g. Wrong drug given but no harm |
Category 3 |
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occurred |
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Injury not requiring first aid |
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Injury or illness, requiring first aid |
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Injury requiring medical treatment |
Category 2 |
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Permanent Incapacity (incl. Psychosocial) |
Category 1 |
E.g. Arm, Spine, Lung, Other Physiological |
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Death |
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SECTION G: TYPE OF INJURY (tick one only )
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Apgar score <5@ 1 min &/or; |
HIE Grade 2 - Hypoxic Ischaemic |
Nerve Injury - face |
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7@5mins &/or pH ≤ 7.0 |
Encephalopathy |
Other unexpected deterioration |
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Aspiration |
HIE Grade 3 - Hypoxic Ischaemic |
Stillbirth |
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Cerebral irritability / neonatal |
Encephalopathy |
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Birth Specific Injury |
seizure |
Hypoglycaemia - severe |
haemorrhage |
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(Baby) |
HIE - Hypoxic Ischaemic |
Kernicterus |
Unknown |
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Encephalopathy with |
Neonatal death |
Other |
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Hypoglycaemia |
Nerve Injury - brachial plexus (incl. |
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HIE Grade 1 - Hypoxic Ischaemic |
Erbs Palsy) |
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Encephalopathy |
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Death |
Perineal tear |
Unknown |
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Birth Specific Injury |
Hysterectomy (Perinatal) |
Uterine rupture |
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(Mother) |
Incontinence (faecal) |
Rhesus |
Other |
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Incontinence (urinary) |
Incontinence (faecal & urinary) |
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Excessive Bleeding |
Febrile |
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Blood Specific Injury |
Fainting |
reaction |
Other |
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Immunological haemolysis |
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Asbestosis |
Hepatitis |
Unknown |
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Diagnosed Disease |
Cancer |
HIV |
Dermatitis |
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Acute Radiation Syndrome |
Brucellosis |
TB |
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Disorder or Cond. |
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Narcolepsy/Cateplexy |
Legionnaires |
Pleural Plaques |
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Other |
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Clostridium Difficle |
Hepatitis |
VRE |
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Diagnosed Infection |
MRSA |
VRSA |
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CPE |
Norovirus |
Other |
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ESBL |
Unknown |
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Allergic Reaction (incl. anaphylaxis) |
Cut / Laceration / Graze / scratch |
Malaise / Nausea |
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Brain Injury / Concussion |
Death |
Nerve injury / Loss of Function |
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Burn / scald / corrosion |
Dental injury &/or loss |
Puncture / bite |
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General Injuries |
Choking / asphyxia |
Deterioration |
Rash / irritation |
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Circulatory / volume depletion |
Haemorrhage |
Unknown |
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Circulatory / volume overload |
Blister |
Other |
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Pain/Discomfort |
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Hearing / Sight Injury |
Hearing Impairment / loss |
Tinnitus |
Other |
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Sight Impairment / loss |
Unknown |
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Misdiagnosis |
Cancer |
Infection |
Other |
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Fracture |
Unknown |
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Amputation |
Fracture |
Swelling / Inflammation |
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Bruising |
Repetitive Strain Injury (RSI) |
Unknown |
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Crushing |
Slipped / Prolapsed Disc |
Whiplash |
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Musculoskeletal |
Dental Fracture / Tooth loss |
Sprain / Strain |
Other |
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Dislocation |
Soft tissue injury |
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/ Soft Tissue |
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P. Ulcer Stage 1: Intact skin with |
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P. Ulcer Stage 2: Part thickness dermis loss: blister/open ulcer/no slough |
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P. Ulcer Stage 3: Full thickness tissue loss: +/- visible subcutaneous fat |
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P. Ulcer Stage 4: Full thickness tissue loss/necrosis: exposed bone/tendon/muscle |
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Additional / Further Surgery |
Loss of Wages / Income / |
Unknown |
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Personal Loss |
Limb Deformity |
Business |
Organ Retention |
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Defamation of Character |
Loss of Consortium |
Other |
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Damage to organ / body part |
Loss of organ / body part |
Unexpected complication / |
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Surgery Specific |
Dental Damage / Loss |
Nerve injury / Loss of |
deterioration |
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Injury |
Foreign body left in situ |
Function |
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Unknown |
Inadequate anaesthesia |
Other |
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Traumatic/Emotional |
Anxiety / Trauma |
Stress |
Worried Well |
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PTSD |
Unknown |
Other |
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HC |
Page 2 of 6 |
SECTION H WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, 3 & 4)
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Step 1. |
Step 2. |
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Step 3. |
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Step 4. |
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Caesarean Section |
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Communication / Consent |
Adverse Effect |
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(Elective) |
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Failure / Malfunction |
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Diagnosis / Assessment |
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Caesarean Section |
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Foreign Body left in Situ |
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Documentation / Records |
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(Emergency) |
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Inappropriate for Task / Wrong device |
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Equipment |
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Instrumental Delivery |
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Incomplete / Inadequate |
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Birth Specific |
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General Care / Management |
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(Forceps) |
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Lack of Availability |
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Procedure / Treatment / |
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Procedures |
Instrumental Delivery |
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Not performed when indicated / Delay |
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Intervention |
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(Vacuum) |
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Pre Existing Medical Condition |
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Screening / Prevention |
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Instrumental Delivery |
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Shoulder Dystocia |
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Specimens / Results |
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(Multiple Instruments) |
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Unavailable / Mislabelled / Lost |
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Tests / Investigations |
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Non Instrumental |
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Wrong Body Part / Site / Side |
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Unknown |
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Delivery |
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Wrong Patient |
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Other |
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Clinical |
Invasive |
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Wrong Process / Treatment / Procedure |
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Procedures |
Non Invasive |
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Other |
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ROUTE OF ADMINISTRATION |
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Adverse Drug Reaction |
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Oral |
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Administration |
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Intravenous |
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Monitoring |
Drug Interaction |
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Sub Cutaneous |
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Ordering / Supply / Transport |
Failure / Malfunction of equipment |
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Preparation / Dispensing |
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Intra Muscular |
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Incomplete / Inadequate |
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(Pharmacy) |
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Topical |
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Not preformed when indicated / |
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Prescribing |
delayed |
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Rectal |
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Medication |
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Reconciliation |
Omitted/Delayed Dose |
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Inhalation |
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Storage |
Wrong Dose / Strength |
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Other / Unknown |
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Wrong Drug |
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WHAT MEDICATION WAS INVOLVED? |
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Wrong Formulation / Route |
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Care |
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Wrong Frequency |
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MEDICATION ONE |
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Wrong Label / Instructions |
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Clinical |
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Wrong Patient |
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MEDICATION TWO |
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Wrong Quantity / Duration |
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Parenteral |
Communication / Consent |
Adverse Effect |
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Enteral |
Prescribing / Requesting |
Incomplete / Inadequate |
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Nutrition |
Special Diet |
Preparation / Dispensing |
Not performed when indicated / Delay |
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General Diet |
Administration |
Wrong Consistency |
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Other |
Storage |
Wrong Diet / Wrong Blood Product |
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Whole Blood |
Documentation / Records |
Wrong Process / Treatment / Procedure |
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Equipment |
Wrong Patient |
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Red Cells |
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Blood / Blood |
Supply / Ordering / Transport |
Lack of Availability |
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Platelet (Apheresis) |
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Product |
Presentation / Packaging |
Wrong dispensing label / instructions |
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Platelets (Pooled) |
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Transfusing blood |
Inappropriate for task / Wrong device |
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Other |
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Other |
Other |
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Diagnostic Exposure > intended |
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Checking Patient ID |
Above Notifiable levels |
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Diagnostic |
Wrong body part / side |
Below Notifiable levels |
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procedure |
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Dose to comforters / carers |
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Radiology (DR) |
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Clinical Details on |
Wrong Patient |
<1mSv |
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& Nuclear |
Referral |
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Inadvertent dose to foetus |
>1mSv |
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Medicine (NM) |
Communication / |
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Total dose or Volume Variation |
<10% |
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Consent |
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Dose (NM) or Volume Variation |
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Documentation / |
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(1 fraction) |
>20% |
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Records |
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Wrong Drug |
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Equipment |
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Wrong Dose |
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Performing procedure |
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Wrong Process / Treatment / |
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Radiotherapy |
Pregnancy Status |
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Intervention |
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Unknown |
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Failure / Malfunction |
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Inadvertent deterministic effects |
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Exposure to Bite (Human) |
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Exposure to Bite (Insect / Animal) |
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Hazards |
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Acquired |
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Exposure to Bodily Fluids |
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Bacteria |
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Exposure to Ingestion/Food/Water |
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Biological |
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Fungus / Mould |
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Exposure to Needle Stick |
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Hazards / |
Please specify, if known: |
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Prion |
Exposure to Skin Contact |
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Bio |
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Infections |
Virus |
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Inhalation/Airborne |
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Organism Unknown |
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Equipment, Implements, Facilities, |
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E.g. |
Sharps (Non Needle) |
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Unknown |
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Other |
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HC |
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
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Step 1. |
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Step 2. |
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Step 3. |
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Absconsion / Missing |
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Attempted Suicide |
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Banging Self Against Walls/Furniture/Surfaces |
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Hitting Body/Slap/Punch Self incl. Scratching & |
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Picking |
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Intentional |
Inappropriate Eating |
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Behaviour |
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Unintentional |
Inappropriate Touching |
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Stripping Clothes in Public Area |
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Suicide |
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Throwing objects |
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Other |
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Aggressive towards inanimate object |
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Violence, Harassment |
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Discrimination/Prejudice/Racial |
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and Aggression |
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Intimidation / Threat |
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Neglect |
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By a Family Member / Relative |
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By a Member of the Public |
Physical Assault / Abuse |
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Child Abuse |
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By a Peer / Student |
Physical Harassment |
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By a Prisoner |
Sexual Assault / Abuse |
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By a Service User |
Sexual Harassment |
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By a Staff Member |
Unintentional Aggressive Behaviour |
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Bullying |
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Adult Abuse |
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Verbal Assault / Abuse |
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Verbal Harassment |
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Other |
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Unknown |
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Pre Existing Medical Condition |
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Inadequate supervision gen health / post op |
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From Height |
Obstruction / protruding object |
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Surface contaminants |
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From Equipment / Furniture |
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Rough terrain / irregular surface |
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Same Level / Ground |
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Slip / Trip / Fall |
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Inappropriate equipment use |
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On Stairs |
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Failure / malfunction of equipment |
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On Steps |
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Horseplay |
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Other |
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Physical training / sport |
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Weather Condition |
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Inadequate Lighting / design |
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Other |
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Object / Tools (Non Sharps) |
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Non Mechanical |
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Sharps (Non Needle) |
Human Use / Error |
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(Incl. Person / Animal) |
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Other |
Obstruction / Protruding Object |
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Person |
Physical Training / Sport |
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Ergonomics |
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Manual Handling |
Defective Equipment |
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Other |
Unsafe / Inappropriate system |
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(Incl. manual / people |
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Patient Handling |
Unknown |
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handling) |
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Restraint / Intervention |
Task |
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Catering equipment |
Load |
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Mechanical |
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Door / Gate / Barrier |
Working Environment |
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Healthcare Equipment |
Individual Capability |
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Components |
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Lifting Equipment / Accessories |
Other |
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Office / Business equipment |
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Temperature |
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Hot |
Liquid / Food / Steam |
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Equipment / Utensils |
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(Excluding Fire) |
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Cold |
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Atmosphere / Environment |
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Fire |
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Defective Equipment |
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Human Use / Error |
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Vibration |
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Please Specify |
Unknown |
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Electrical |
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Unsafe System |
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Noise |
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Explosion |
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Exposure |
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Radiation |
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Electrical Wiring / installation |
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HC |
Page 4 of 6 |
SECTION H CNTD: WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, & 3)
|
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Step 1. |
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Step 2. |
|
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Step 3. |
|
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|
|||
|
|
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Animal Remedy |
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Insecticide |
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Arsenic |
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Lead |
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Acid / Alkaline |
Asbestos |
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Metallic Dust |
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Bleach |
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Motor / Gear / Hydraulic Oil |
|
|
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Agri Chemicals |
Cadmium |
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Natural Gas |
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Hazards |
Gas |
Carbon Dioxide |
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Organic Dust |
|
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Carbon Monoxide |
|
Paint / Paint Product |
|
|
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|
Other Chemical |
|
|
|
||||
|
Chemical Fertilizer |
|
Petrol |
|
|
|||
|
Products |
|
Lack of Supervision |
|
||||
|
Crystalline Silica |
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Polish |
|
||||
|
|
Unknown |
|
|||||
|
Chemical |
Particulates |
Detergent |
|
Radon |
|
||
|
|
Human / User Error |
|
|||||
|
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Diesel / Kerosene |
|
Rodenticide |
|
|||
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Petroleum / Synthetic |
|
Unsafe System |
|
||||
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Disinfectant |
|
Soap |
|
||||
|
Oil Based Products |
|
|
|
||||
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Drain / Oven Cleaner |
|
Sodium Hydroxide |
|
|
|||
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Sanitation / Cleaning |
|
|
|
||||
|
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Drugs |
|
Solvents |
|
|
||
|
|
Chemicals |
|
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|
|||
|
|
Fungicide |
|
Spent / Used Oil Product |
|
|
||
|
|
|
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|
|||
|
|
Toxic Metals |
Glue / Adhesive |
|
Sulphuric Acid |
|
|
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|
|
Grease |
|
Wrong Patient |
|
|
|
|
|
|
Herbicide |
|
Other |
|
|
|
|
|
|
Hydrochloric Acid |
|
|
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|
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|
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|
|
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|
|
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 |
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|
|
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 |
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 |
Page 6 of 6 |