# 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.

<!--
Guidance: How to use this template
- Report first, review second. Part A (sections 1 to 5) is the initial
  report: complete it as soon as the patient is safe, in the same shift
  if possible. Part B (sections 6 to 9) is the learning review, done
  later by a person or team who was not involved.
- Describe facts, not blame. Write what happened and what was found, not
  who was careless. Safety science treats most incidents as products of
  the system the staff worked in.
- Report near misses too. An incident that did not reach the patient
  shows the same weak defences as one that did, at no cost to a patient.
- Check whether a statutory or contractual duty is triggered, for
  example openness with the patient (duty of candour in England), a
  mandatory regulator notification or an external reporting system.
  Your patient safety team decides; this form only records it.
- Related templates: Root Cause Analysis
  (`healthcare/root-cause-analysis`) for a full investigation, PDSA
  Cycle (`healthcare/pdsa-cycle`) to test the safety actions, SBAR
  (`healthcare/sbar`), Clinical Audit (`healthcare/clinical-audit`),
  Medication Reconciliation (`healthcare/medication-reconciliation`).
-->

## Document control

<!-- Guidance: The incident ID comes from your local reporting system. Keep the classification at the highest level the content needs: an identifiable incident report is part of the confidential record. -->

| 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

<!-- Guidance: Record what was done to make the patient and others safe before anything else. Pitfall: a report that describes the error in detail but not whether the patient was reviewed. -->

| 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

<!-- Guidance: A short factual account in time order: what was planned, what happened instead, and how it was found. No opinions on cause here; those belong in Part B. -->

[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

<!-- Guidance: Use the WHO ICPS terms so reports can be compared across units and organisations. Pick the incident category that best fits; your local system may use its own list mapped to the ICPS class "Incident Type". -->

| 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

<!-- Guidance: Record how the patient and family were told and supported, and whether they want to take part in the review. Many systems treat this as the first priority after clinical care. -->

| 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

<!-- Guidance: Staff involved in an incident are often affected by it. Record that support was offered, never the content of any conversation. -->

- 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

<!-- Guidance: Choose a response proportionate to the learning available, not only to the harm. Most incidents need a short review; a full investigation is kept for incidents where it adds new learning or where it is required. -->

| 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

<!-- Guidance: Describe the system factors, not just the last person who touched the case. Use the ICPS class "Contributing factors or hazards" as prompts (staff, patient, work environment, organisational or service, and external factors), plus the task, team and equipment factors that many local systems add. -->

| 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

<!-- Guidance: Prefer actions that change the system (forcing functions, standard processes, staffing) over weak actions such as reminders and training alone. Each action has an owner, a date and a measure. -->

| 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 |

```mermaid
flowchart LR
    R["Incident reported"] --> S["Patient safe, family told"]
    S --> D{"Learning response needed?"}
    D -- "No, learning known" --> C["Close with reason"]
    D -- "Yes" --> M["Choose proportionate method"]
    M --> F["Findings: system factors"]
    F --> A["Safety actions with owners"]
    A --> T["Monitor measures"]
    T --> C
```

## 9. Sharing and closure

<!-- Guidance: Close only when actions are assigned and monitoring is in place. Share de-identified learning beyond the unit. -->

| 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

<!-- Guidance: Name the local policy and version the review followed. -->

| 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.