Patient Safety Incident Report Template

Incident report and learning review: immediate actions, WHO ICPS classification and harm, family involvement, learning response, findings, safety actions

医療標準WHO ICPS conceptual framework (2009); NHS PSIRF and US PSQIA 2005 as examplespatient safety incident report更新 2026/10/29

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使い方: Use it when a patient safety incident or near miss happens. Fill the immediate actions and the factual account first, then choose a proportionate learning response. The main pitfall is blaming the last person involved instead of finding the system factors.

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Patient Safety Incident Report and Learning Review: [Short incident title]

Report of a patient safety incident and the proportionate learning response that follows it. Incident terms and the harm scale follow the WHO Conceptual Framework for the International Classification for Patient Safety (ICPS, WHO/IER/PSP/2010.2, January 2009). The learning review section is neutral and international; dated examples show how England (NHS Patient Safety Incident Response Framework, PSIRF) and the US (patient safety work product under the Patient Safety and Quality Improvement Act of 2005) frame the same work. Replace every [bracketed] value and every row marked Example. This is a documentation format, not legal or medical advice; check the current official texts, your organisation's policy and a qualified professional. Never put patient or staff identifiers in a report that leaves the protected reporting system.

Document control

Field	Value
Incident ID	[INC-YYYY-NNNN]
Reporting system reference	[Local system ID / external system ID]
Date and time of incident	YYYY-MM-DD HH:MM
Date and time reported	YYYY-MM-DD HH:MM
Location	[Site, unit, area]
Reporter	[Role only, contact held in the reporting system]
Learning response lead	[Name, role]
Version	[0.1]
Status	[Reported / Under review / Learning response in progress / Closed]
Owner	[@patient-safety-lead]
Approvers/reviewers	[@clinical-director], [@patient-safety-team]
Last updated	YYYY-MM-DD
Classification	[Confidential: patient safety]

Revision history

Version	Date	Author	Change
0.1	YYYY-MM-DD	[Role]	Initial report
0.2 (Example)	YYYY-MM-DD	[Role]	Learning response method agreed
1.0 (Example)	YYYY-MM-DD	[Role]	Review completed, actions signed off

Part A: Incident report

Sections 1 to 5 are completed by the reporter or the person in charge, as soon as the patient is safe.

1. Immediate actions

Action	By (role)	Time
Patient assessed and treated	[Role]	HH:MM
Senior clinician informed	[Role]	HH:MM
Equipment, medicine or sample kept for review	[Yes / no / not applicable]	HH:MM
Patient or family told what happened	[Yes / not yet, reason]	HH:MM
Immediate risk to others removed	[Action]	HH:MM

2. What happened

[Factual description in time order]

Example: At the fictional Halvermoor District Hospital, a patient admitted at 23:10 was prescribed their usual anticoagulant twice daily. The home medicine list showed once daily. The 08:00 dose was given. At 10:30 the ward pharmacist found the discrepancy during medicines reconciliation; the second dose was held and the prescriber corrected the chart.

3. Classification

Field	Value
Incident or circumstance	[Reportable circumstance / near miss / no harm incident / harmful incident (adverse event)]
Incident type	[Clinical administration / clinical process or procedure / documentation / healthcare-associated infection / medication or IV fluids / blood or blood products / nutrition / oxygen, gas or vapour / medical device or equipment / behaviour / patient accident / infrastructure, building or fixtures / resources or organisational management]
Degree of harm (ICPS)	[None / mild / moderate / severe / death]
How detected	[Who or what found it]
Mitigating factors	[What stopped it getting worse]
Example	No harm incident, medication, degree of harm none, detected by pharmacist reconciliation, mitigated by holding the second dose

ICPS terms in brief: a reportable circumstance had significant potential for harm but no incident occurred; a near miss did not reach the patient; a no harm incident reached the patient with no discernible harm; a harmful incident (adverse event) resulted in harm. Harm is graded none, mild, moderate, severe or death.

4. Patient and family involvement

Item	Detail
Told by	[Role], YYYY-MM-DD
Apology given	[Yes / no]
Statutory openness duty applies?	[Yes / no / to be decided by the patient safety team]
Written follow-up sent	[Yes, date / not required]
Wishes about involvement in the review	[Summary]
Named contact for the family	[Role]

5. Staff support

Support offered to staff involved: [Yes, by whom / declined]
Debrief held: [Yes, date / no]

Part B: Learning review

Sections 6 to 9 are completed by the learning response lead, who was not involved in the incident.

6. Choosing the learning response

Method	Typical use	Chosen?
Rapid team huddle	Soon after the event, to capture facts and fix immediate risks	[ ]
After action review	Structured team conversation: what was expected, what happened, why the difference, what to learn	[ ]
Multidisciplinary review	Several similar incidents, or one that crosses services	[ ]
Thematic review of reports	Look across many low-harm incidents for a pattern	[ ]
Full systems investigation	High learning potential or required by policy or regulation; see `healthcare/root-cause-analysis`	[ ]
No further review	Learning already known and covered by existing work	[ ]

Decision and reason: [Method, decided by whom, date]

Dated jurisdiction examples:

Jurisdiction	Framework	What it changes for this form
England (NHS)	Patient Safety Incident Response Framework (PSIRF), NHS England, first published August 2022, replaced the Serious Incident Framework. Its four aims are compassionate engagement of those affected, system-based approaches to learning, considered and proportionate responses, and supportive oversight. Learning response methods include after action review, swarm huddle, multidisciplinary team review and patient safety incident investigation (PSII)	Choose the method from the organisation's PSIRF plan; record national reporting in the national system
United States	Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41, approved 29 July 2005); reports prepared for a listed Patient Safety Organization can be privileged patient safety work product	Ask your legal or risk team how this form is labelled and stored before you share it

7. Findings

ID	Factor	Category	Evidence
F-01 (Example)	Night admissions are prescribed before a full medicine history is available	Task and process	Two similar reports in six months in the reporting system
F-02 (Example)	Pharmacist reconciliation does not take place at night or at weekends	Organisation and resources	Rota
F-03 (Example)	The prescribing screen does not show the last community dispensing record	Equipment and IT	System walkthrough

What went well: [Defences that worked, for example the pharmacist check]

8. Safety actions

ID	Action	Addresses	Strength	Owner	Due	Measure
SA-01 (Example)	Add community dispensing record to the admission prescribing screen	F-03	Stronger: system change	[IT lead]	YYYY-MM-DD	Screen live, audit of 20 admissions
SA-02 (Example)	Test a weekend medicine history rota with PDSA cycles	F-02	Intermediate: process and staffing	[Pharmacy lead]	YYYY-MM-DD	Percent reconciled within 24 hours, run chart
SA-03 (Example)	Share this case at the medical induction	F-01	Weaker: education	[Education lead]	YYYY-MM-DD	Delivered

9. Sharing and closure

Item	Detail
Findings shared with patient or family	[Yes, date / declined]
Learning shared with	[Unit meeting, safety bulletin, governance committee]
External reporting completed	[System, reference, date / not required]
Closed by	[Role], YYYY-MM-DD

References

Reference	Status	Use
WHO. Conceptual Framework for the International Classification for Patient Safety, version 1.1, final technical report, January 2009 (WHO/IER/PSP/2010.2), https://www.who.int/publications/i/item/WHO-IER-PSP-2010.2	Checked 2026-10-30 (WHO page and PDF)	Incident terms, degree of harm, ten high-level classes
WHO. Global Patient Safety Action Plan 2021-2030 (3 August 2021), https://www.who.int/publications/i/item/9789240032705	Checked 2026-10-30	International policy context
NHS England. Patient Safety Incident Response Framework and supporting guidance, https://www.england.nhs.uk/patient-safety/patient-safety-insight/incident-response-framework/	Official page blocked automated access; aims and methods confirmed from an NHS-funded provider policy, 2026-10-30	England example
Patient Safety and Quality Improvement Act of 2005, Public Law 109-41, https://www.govinfo.gov/app/details/PLAW-109publ41	Checked 2026-10-30	US example

Standard and licence note

Based on the WHO Conceptual Framework for the ICPS (January 2009) for terms and harm grades, with dated examples from NHS England PSIRF and the US Patient Safety and Quality Improvement Act of 2005. The ICPS may not be reproduced without WHO consent, so this template names its terms and classes and paraphrases them in original words. All names, organisations and events in examples are fictional. This is a documentation format, not legal or medical advice; check the current official texts and your organisation's policy. Template licence: MIT.