Fillable HC NIRF 01 V12 Date issued: 26/11/2021 Specific (Ireland - Health Service Executive)

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HC NIRF 01 V12 Date issued: 26/11/2021 Specific (Ireland - Health Service Executive)

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HC NIRF 01 – V12
Date issued: 26/11/2021
NATIONAL INCIDENT REPORT FORM (NIRF)
NIRF - 01 PERSON
NIMS record Number:
Page 1 of 7
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 incident
Use 24 hour clock
Location
E.
g. Hospital, Health Centre, Residential Centre etc.
Offsite?
First name
____________________________
Surname
____________________________
Date of birth
Female
Male
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
Panel staff / Agency / Locum – Go to section D
Member of the public – Proceed to section F
Volunteer – Go to section D
External Contractor – Go to section E
Work Placement / Trainee – Go to section D
SECTION C: SERVICE USER DETAILS ONLY
Healthcare Record No ____________________________
Lead Clinician ____________________________
This incident involved… (tick one only )
Neonatal Specialties
Paediatric Specialties
Adolescent Specialties
Adult Specialties
Older Person Specialties
Incident Occurred under
(Service / Specialty)
E.g. Antenatal, Audiology,
Radiotherapy, Intellectual Disability,
Psychology
__________________________
SECTION D: STAFF MEMBER / AGENCY / PANEL STAFF
/ WORK PLACEMENT / VOLUNTEER DETAILS ONLY
Category of person ____________________________
Employee no. ____________________________
Date absence commenced
(if known)
Date returned to work
(if known)
Lost Days
SECTION E: EXTERNAL CONTRACTOR DETAILS ONLY
Company name ____________________________
Company no. ____________________________
Specific Location
E.g. Ward, Clients home etc.
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
HC NIRF-01
Page 2 of 7
SECTION G: TYPE OF INJURY (tick one only )
Birth Specific Injury
(Baby)
Apgar score <5@ 1 min &/or;
7@5mins &/or pH ≤ 7.0
Aspiration
Cerebral irritability / neonatal
seizure
HIE - Hypoxic Ischaemic
Encephalopathy with Hypoglycaemia
HIE Grade 1 - Hypoxic Ischaemic
Encephalopathy
HIE Grade 2 - Hypoxic Ischaemic
Encephalopathy
HIE Grade 3 - Hypoxic Ischaemic
Encephalopathy
Hypoglycaemia - severe
Kernicterus
Neonatal death
Nerve Injury - brachial plexus (incl.
Erbs Palsy)
Nerve Injury - face
Other unexpected deterioration
Stillbirth
Sub-galeal / sub-aponeurotic
haemorrhage
Unknown
Other ____________________
Birth Specific Injury
(Mother)
Death
Hysterectomy (Perinatal)
Incontinence (faecal)
Incontinence (urinary)
Perineal tear
Post-Partum Haemorrhage
Rhesus iso-immunisation
Incontinence (faecal & urinary)
Unknown
Uterine rupture
Other ____________________
Blood Specific Injury
Excessive Bleeding
Fainting
Immunological haemolysis
Febrile non-haemolytic transfusion
reaction
Non-immunological haemolysis
Other ____________________
Diagnosed Disease
Disorder or Cond.
Asbestosis
Cancer
Acute Radiation Syndrome
Narcolepsy/Cateplexy
Hepatitis
HIV
Brucellosis
Legionnaires
Unknown
Dermatitis
TB
Pleural Plaques
Other ____________________
Diagnosed Infection
Clostridium Difficle
COVID-19
CPE
ESBL
Hepatitis
MRSA
Norovirus
Unknown
VRE
VRSA
Other ____________________
General Injuries
Allergic Reaction (incl. anaphylaxis)
Brain Injury / Concussion
Burn / scald / corrosion
Choking / asphyxia
Circulatory / volume depletion
Circulatory / volume overload
Pain/Discomfort
Cut / Laceration / Graze / scratch
Death
Dental injury &/or loss
Deterioration
Haemorrhage
Blister
Malaise / Nausea
Nerve injury / Loss of Function
Puncture / bite
Rash / irritation
Unknown
Other ____________________
Hearing / Sight Injury
Hearing Impairment / loss
Sight Impairment / loss
Tinnitus
Unknown
Other ____________________
Misdiagnosis
Cancer
Fracture
Infection
Unknown
Other ____________________
Musculoskeletal
/ Soft Tissue
Amputation
Bruising
Crushing
Dental Fracture / Tooth loss
Dislocation
Fracture
Repetitive Strain Injury (RSI)
Slipped / Prolapsed Disc
Sprain / Strain
Soft tissue injury
Swelling /
Inflammation
Unknown
Whiplash
Other ____________________
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
Personal Loss
Additional / Further Surgery
Limb Deformity
Defamation of Character
Loss of Wages / Income /
Bus
i
n
e
s
s
Loss of Consortium
Unknown
Organ Retention
Other ____________________
Surgery Specific
Injury
Damage to organ / body part
Dental Damage / Loss
Retained foreign object
Unknown
Loss of organ / body part
Nerve injury / Loss of
Function
Inadequate anaesthesia
Unexpected complication /
d
e
te
r
i
o
rati
o
n
Other ____________________
Traumatic/Emotional
Anxiety
/
T
rauma
PTSD
Stress
Unknown
Worried Well
Other ____________________
SECTION F: WHAT WAS THE OUTCOME AT THE TIME OF THE INCIDENT?
Outcome Body Part Affected
Near Miss e.g. Nearly given wrong drug
Category 3
No Injury e.g. Wrong drug given but no harm
occurred
Injury not requiring first aid
Injury or illness, requiring first aid
Injury requiring medical treatment
Category 2
Long-term disability / Incapacity (incl. psychosocial)
Category 1
Permanent Incapacity (incl. Psychosocial)
Death
E.g. Arm, Spine, Lung, Other Physiological
HC NIRF-01
Page 3 of 7
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.
Labour/Delivery
Assessment/Monitoring
Tests/Investigations
T
reatment
/Interventi
on
Care process
Delivery type
Caesarean
Section (Elective)
Caesarean
Secti
on (Emerg
ency)
I
nstrumental
Deli
very (Forceps)
Instrumental D
eli
ve
ry (Vac
uu
m
/
V
en
tuse/Kiwi)
Instrumental Deli
very
(Mul
ti
ple
I
nstruments)
Non
I
nstrumental De
l
i
very
Adverse event:
Cord Prolapse
Eclampsia
Low Apgars/Cord PH
Placental Abruption
PPH
Shoulder Dystocia
Uterine Rupture
Other
Adverse event requiring transfer/
return to theatre:
Cord Prolapse
Ecl
ampsi
a
Low Apgars/Cord PH
Pl
acental
Abruption
PPH
Shoulder Dystoci
a
Uterine Rupture
Other
Incomplete/inadequate:
Communication
Consent
Documentation
Equipment
Unknown/other
Lack of availability
Not performed when indicated/Delayed
Retained foreign object
Wrong process/treatment/procedure
Diagnosis
Delayed Diagnosis
Misdiagnosis/Incorrect Diagnosis
Missed Diagnosis
Diagnosis Type
Assessment/Monitoring
Tests/Investigations
Test Interpretation
Care
process
Incomplete/inadequate:
Communication
Consent
Documentation
Equi
pment
Unknown/other
Lack of availability
Not performed when indicated/Delayed
Other adverse event/Patient safety incident
Care
Management
Stage of Care
Community
Outpatient/ED
Inpatient
Assessment/Monitoring
Tests/Investigations
T
reatment/Interventi
on
Care process
Incomplete/inadequate:
Communication
Consent
Documentation
Equipment
Unknown/other
Lack of availability
Not performed when indicated/Delayed
Pre-existing medical condition
Retained foreign object
Wrong body part/site/side
Wrong patient
Wrong process/treatment/procedure
Other adverse event/Patient safety incident
Stage of Care
Pre Procedure
Intra Procedure
Post Procedure
Assessment/Monitoring
Tests/Investigations
Treatment/Intervention
Care
process
Incomplete/inadequate:
Communication
Consent
Documentation
Equipment
Unknown/other
Lack of availability
Not performed when indicated/Delayed
Retained foreign object
Wrong body part/site/side
Wrong patient
Wrong process/treatment/procedure
Other adverse event/Patient safety incident
Surgical/Medical
Procedures
Name of Initial Procedure
Name of Subsequent Procedure
(e.g if required return to theatre)
e.g. cannulation, colonoscopy
e.g. EUA, hysterectomy
Clinical Care
HC NIRF-01
Page 4 of 7
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.
Clinical Care
Medication
Route of administration
Oral
Intravenous
Sub Cutaneous
Intra Muscular
Topical
Rectal
Inhalation
Other / Unknown
Administration
Monitoring
Ordering / Supply / Transport
Preparation / Dispensing
(Pharmacy)
Prescribing
Reconcil
iation
Storage
Adverse Drug Reaction
Contra-indicated
Drug Interaction
Failure / Malfunction of equipment
Incomplete / Inadequate
Not preformed when indicated /
delayed
Omitted/Delayed Dose
Wrong Dose / Strength
Wrong Drug
Wrong Formulation / Route
Wrong Frequency
Wrong Label / Instructions
Wrong Patient
Wrong Quantity
/ Duration
What medication was involved?
Medication One ______________________________
Medication Two _______________________________
Nutrition
Parenteral
Enteral
Special Diet
General Diet
Other ______________
Communication / Consent
Prescribing / Requesting
Preparation / Dispensing
Administration
Storage
Documentation / Records
Equipment
Supply / Ordering / Transport
Presentation / Packaging
Transfusing blood
Other___________________
Adverse Effect
Incomplete / Inadequate
Not performed when indicated / Delay
Wrong Consistency
Wrong Diet / Wrong Blood Product
Wrong Process / Treatment / Procedure
Wrong Patient
Lack of Availability
Wrong dispensing label / instructions
Inappropriate for task / Wrong device
Other___________________________
Blood / Blood
Product
Whole Blood
Red Cells
Platelet (Apheresis)
Platelets (Pooled)
Other ______________
Diagnostic
Radiology (DR)
& Nuclear
Medicine (NM)
Checking Patient ID
procedure
Clinical Details on
Referral
Communication /
Consent
Documentation /
Records
Equipment
Performing procedure
Pregnancy Status
Unknown
Diagnostic Exposure > intended
X-ray Over Exposure
Wrong body part / side
Dose to comforters / carers
Above Notifiable levels
Below Notifiable levels
Wrong Patient
Inadvertent dose to foetus
<1mSv
>1mSv
Total dose or Volume Variation
Dose (NM) or Volume Variation
(1 fraction)
<10%
10-20%
>20%
Radiotherapy
Wrong Drug
Wrong Dose
Wrong Process / Treatment /
Intervention
Failure / Malfunction
Inadvertent deterministic effects
Bio Hazards
Biological
Hazards /
Acquired
Infections
Bacteria
Fungus / Mould
Prion
Virus
Organism Unknown
Exposure to Bite (Human)
Exposure to Bite (Insect / Animal)
Exposure to Bodily Fluids
Exposure to Ingestion/Food/Water
Exposure to Needle Stick
Exposure to Skin Contact
Inhalation/Airborne
Equipment, Implements, Facilities, Sharps
(Non Needle)
Unknown
Other ____________________
Please Specify, if known
______________________________
e.g COVID-19, MRSA, etc
HC NIRF-01
Page 5 of 7
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.
Behavioural Hazards
Self-Injurious
Behaviour
Intentional
Unintentional
Absconsion / Missing
Attempted Suicide
Banging Self Against Walls/Furniture/Surfaces
Hitting Body/Slap/Punch Self incl. Scratching & Picking
Inappropriate Eating
Inappropriate Touching
Self-Harm
Stripping Clothes in Public Area
Suicide
Throwing objects
Other __________________________
Violence,
Harassment and
Aggression
By a Family Member / Relative
By a Member of the Public
By a Peer / Student
By
a Prisoner
By a Service User
By a Staff Member
Please specify name of instigator
Aggressive towards inanimate object
Discrimination/Prejudice/Racial
Intimidation / Threat
Neglect
Non-Compliant / Obstructive / Rude
Direct Physical Assault
Physical Harassment
Sexual Assault / Abuse
Sexual Harassment
Unintentional Aggressive Behaviour
Bullying
Verbal Assault / Abuse
Verbal Harassment
Other ____________________
Child Abuse
Adult Abuse
Physical Hazards
Slip / Trip / Fall
From Height
From Equipment / Furniture
Same Level / Ground
On Stairs
On Steps
Other ____________________
Unknown
Pre Existing Medical Condition
Inadequate supervision gen health / post op
Obstruction / protruding object
Surface contaminants
Rough terrain / irregular surface
Inappropriate equipment use
Failure / malfunction of equipment
Horseplay
Physical training / sport
Weather Condition
Inadequate Lighting / design
Other ____________________
Non Mechanical
(Incl. Person /
Animal)
Object / Tools (Non Sharps)
Sharps (Non Needle)
Other
Person
Human Use / Error
Obstruction / Protruding Object
Physical Training / Sport
Defective Equipment
Unsafe / Inappropriate system
Unknown
Task
Load
Working Environment
Individual Capability
Other ____________________
Ergonomics
(Incl. manual /
people handling)
Manual Handling
Other
Patient Handling
Physical Intervention
Mechanical
Components
Catering equipment
Door / Gate / Barrier
Healthcare Equipment
Lifting Equipment / Accessories
Office / Business equipment
Temperature
(Excluding Fire)
Hot
Cold
Liquid / Food / Steam
Equipment / Utensils
Atmosphere / Environment
Fire
Vibration
Electrical
Noise
Radiation
Please Specify
_______________________
Defective Equipment
Human Use / Error
Unknown
Unsafe System
Explosion
Exposure
Electrical Wiring / installation
__________________________________
HC NIRF-01
Page 6 of 7
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.
Chemical Hazards
Acid / Alkaline
Agri Chemicals
Gas
Other Chemical
Products
Particulates
Petroleum / Synthetic
Oil Based Products
Sanitation / Cleaning
Chemicals
Toxic Metals
Animal Remedy
Arsenic
Asbestos
Bleach
Cadmium
Carbon Dioxide
Carbon Monoxide
Chemical Fertilizer
Crystalline Silica
Detergent
Diesel / Kerosene
Disinfectant
Drain / Oven Cleaner
Drugs
Fungicide
Glue / Adhesive
Grease
Herbicide
Hydrochloric Acid
Insecticide
Lead
Metallic Dust
Motor / Gear / Hydraulic Oil
Natural Gas
Organic Dust
Paint / Paint Product
Petrol
Polish
Radon
Rodenticide
Soap
Sodium Hydroxide
Solvents
Spent / Used Oil Product
Sulphuric Acid
Wrong Patient
Other
____________________
Lack of Supervision
Unknown
Human / User Error
Unsafe System
SECTION I: IMMEDIATE ACTIONS TAKEN
SECTION K: REPORTED BY: person who discovers the incident and unless
otherwise stated within the organization, this person is responsible for completing the NIRF.
First name
__________________________________
__________________________________
E.g. Nurse, Catering Staff, Cleaner
__________________________________
Surname
Date notified
Category of person
Local system reference
no.
Date
Contact Details
__________________________________
SECTION L: WITNESS DETAILS (Name, Contact No. etc.)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
(For entry on Incident Review screen on NIMS)
HC NIRF-01
Page 7 of 7
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:
SAO Email and Contact Details:
_________________________________ Date notified to SAO:
_________________________________________________________________________________
Is there a requirement to report this incident to any external
regulators/agencies/insurers (other than the State Claims Agency)?
Yes No
Date Notified:
_________________________
If Yes: Name regulator(s)/agency(ies) reported/notified to:
1 __________________________________________________________________________
2 __________________________________________________________________________
3 __________________________________________________________________________
_________________________________ Title: Line/Department Manager name:
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:
____________________________________________
Date:
*Mandatory Fields
(For entry on Incident Review screen on NIMS)
(For entry on Incident Review screen on NIMS)
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HC NIRF 01 V12 Date issued: 26112021 Specific (Ireland - Health Service Executive)

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Completed 11 January 2022

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