Preview of Reporting Form Questions

• Step 1
• Step 2
• Step 3
  
• Step 4
• Step 5
• Step 6
• Step 7
  

Step 1

• Please tell us who you are:

• the person affected
• a relative, partner, friend or carer
• someone else

• At what stage during your care did the incident occur:

• Availability of / access to care (see examples)
• Diagnosis (see examples)
• Treatment (see examples)
• Discharge (see examples)
• Ongoing or follow up care (see examples)
• Other - please define here:

• *Was the incident related to (tick one or more):

• Availability of staff / services (see examples)
• Co-ordination of care (see examples)
• Devices / equipment (see examples)
• Infections (see examples)
• Lack of communication (see examples)
• Medication problem (see examples)
• Patient notes / record (see examples)
• Patient accident (see examples)
• Self-harm (see examples)
• Staff failed to check the patient (see examples)
• Staff member's ability (see examples)
• Abuse (see examples)
• Unknown
• Other -please define here:

Step 2

• Please tell us what you were being treated for?

• *Did you suffer any physical / mental harm?
  • Yes
  • No

• Which of these most accurately describes the harm you suffered?
  • You needed extra observation or minor treatment
  • You needed further treatment or another procedure
  • You suffered permanent or long-term harm
  • None of the above

• Please tell us how this experience has affected you?

Step 3

• In which country did this incident occur?
  • England
  • Wales
  • Other – please define here:

• Was the incident related to an overnight stay in a hospital or a mental health unit / facility?
  • Yes
  • No

Step 4

• Ambulance / patient transport service

• Call / control centre
• In vehicle
• Other - please define here:

• Hospital

• A&E
• Outpatient department
• Day care
• Intensive care unit
• Operating theatre
• Ward
• Other - please define here:

• Mental health unit / facility

• Community setting
• Day care
• Secure unit
• Ward
• Other - please define here:

• Learning Disabilities  unit / facility

• Community setting
• Day care
• Secure unit
• Ward
• Other - please define here:

• If you selected Hospital Outpatient Department, Hospital Day Care or Hospital Ward above, please tell us the type of care you received:

• Diagnostic
• Medical (for example cardiology, oncology)
• Obstetrics, gynaecology and fertility treatment
• Surgical
• Other - please define here:

• When did you become aware that an incident had occurred?

• Immediately
• Later. If known, please tell us the date (for example 19/12/2004)
• Unknown

• When did the incident happen?
  • Date (for example 19/12/2004)
  • Unknown

• Did it occur during the:
  • Day (07h00-21h00)
  • Night (21h00-07h00)
  • Unknown

• If there were a series of incidents, please tell us the start and end dates:
  • Start date (for example 19/12/2004)
  • End date (for example 19/12/2004)
  • This is still ongoing

Step 5

• Ambulance staff
• Doctor
• Dentist / Dental nurse
• Health visitor
• Midwife
• Nurse
• Optician
• Therapist
• Chemist
• Unknown
• Other - please define here:

• Did staff tell you what went wrong?
  • Yes
  • No
  • Not sure

• If staff did not tell you what went wrong, how did you find out?

• Was language an issue?
  • Yes
  • No
  • Not sure
• Why do you think this incident happened?

Step 6

• Please describe your gender

• Male
• Female
• Other - please define here

• *Please tell us your age at the time

• Under 16
• 16 - 24 years
• 25 - 34 years
• 35 - 44 years
• 45 - 54 years
• 55 - 64 years
• 65 - 74 years
• 75 - 84 years
• 85 years and over

• *Please describe your ethnic origin

• Asian or Asian British
  • - Indian
  • - Pakistani
  • - Bangladeshi
  • - Other - please define here:

• Black or Black British
  • - Caribbean
  • - African
  • - Other - please define here:

• Mixed
  • - White and Black Caribbean
  • - White and Black African
  • - White and Asian
  • - Other - please define here:

• White
  • - White British
  • - White Irish
  • - Other - please define here:

• Chinese or other ethnic group
  • - Chinese
  • - Other - please define here:

• I do not wish to disclose this information.

• *Do you have any of the following known / diagnosed impairments or disabilities?

• - Learning difficulty(ies)
• - Physical disability(ies)
• - Sensory impairment(s)
• - I do not wish to disclose this information
• - No impairment(s) / disability(ies)

• Please tell us your religion

• - Buddhist
• - Christian
• - Hindu
• - Jehovah's Witness
• - Jewish
• - Muslim
• - Sikh
• - No religion
• - Other religion - please define here:
• - I do not wish to disclose this information

• Please tell us your sexual orientation

• - Heterosexual
• - Homosexual
• - Bisexual
• - Other - please define here:
• - I do not wish to disclose this information

Step 7

• Have you already reported the incident and if so to whom?
• If this has been reported, then please tell us what happened?
• How did you find about the NPSA (National Patient Safety Agency)?
• Is there anything else you would like to tell us about this incident?