AIF1(Pharmacy Anon)
REPORTING OF ADVERSE INCIDENTS
By COMMUNITY PHARMACY SERVICES
*Fields 1-5 Not applicable if reporting anonymously
6.
Date of Incident:
9.
Patient Involved? Yes / No
7.
10.
Date Aware:
8.
Date of Report:
Age:
11.
Sex:
(please delete)
12.
13.
Medication Incident? Yes / No (please delete)
If Yes please give name (s) of medication involved:
14.
Other HSC Organisation Involved? Yes / No (please delete)
15.
More details on HSC organisation (if willing to provide them)
16.
Brief summary of incident (Should not contain personal detail of patient)
Include relevant information regarding the incident eg name, form, dose and quantity of medications
prescribed and same for those dispensed (if different), whether the patient actually consumed the medication
and any harm that occurred.
16a Please indicate whether this was a ‘near miss’ or a dispensing error:
□ near miss
□ dispensing error
□ other
‘Near miss’ is defined as an incident detected up to and including the point at which the medication was
handed over to the patient or patient’s representative. Dispensing error is an incident detected after the
patient had taken possession of the medication.
16b Level of harm and likelihood of re-occurrence: † See risk analysis table (Appendix 1) for
definitions of these terms
If harm occurred please indicate the actual level of harm† caused to the patient by this incident:
Insignificant □
minor □
moderate □
major □
Catastrophic □
unknown □
n/a □
PLEASE NOTE THAT THIS INFORMATION WILL BE TREATED ANONYMOUSLY
AND WILL NOT BE USED FOR ANY PURPOSE OTHER THAN LEARNING.
Please post completed document to:
Medicines Governance Adviser, Integrated Care, Local HSCB Office
AIF1(Pharmacy Anon)
Had the error gone unnoticed, please indicate the
level of harm† you think could have occurred to
the patient:
Please indicate your perceived likelihood that
this could happen again, in your or another
pharmacy:
Insignificant □ minor □ moderate □ major □
Rare □ unlikely □ possible □ likely □
Catastrophic □
almost certain □
17.
unknown / unpredictable
□
Possible Cause / Contributory Factors
17a Please indicate how busy the pharmacy was at the time of the incident
□ Very busy
□ busy
□ average
□ quiet
18.
Action taken by contractor with regard to this event:
19.
Action taken by contractor to prevent recurrence:
□ very quiet
Please tick the box(es) that best describe(s) this error/near miss (tick as many as are applicable):
□ Dose or strength was wrong or unclear
□ Verbal direction to patient was wrong or omitted
□ Expiry date wrong, omitted or passed
□ Wrong/transposed/omitted medicine label
□ Formulation of medication was wrong
□ Wrong drug/medicine
□ Frequency for taking of medication was wrong
□ Wrong method of preparation or supply
□ Medication incorrectly stored
□ Wrong quantity
□ Mismatch between patient and medicine
□ Contra-indication to the use of the medication
□ Omitted medicine or ingredient
□ Medication prescribed to which patient had a
known allergy
□ Other medication incident
□ Patient information leaflet wrong or omitted
□ Omitted dose
□ Wrong route of administration of medication
HSCB Use Only: FPS Reference No
Logged by
Date
PLEASE NOTE THAT THIS INFORMATION WILL BE TREATED ANONYMOUSLY
AND WILL NOT BE USED FOR ANY PURPOSE OTHER THAN LEARNING.
Please post completed document to:
Medicines Governance Adviser, Integrated Care, Local HSCB Office
AIF1(PharmacyAnon)
Appendix 1: Risk Analysis Table
DOMAIN
INSIGNIFICANT (1)
PEOPLE
(Impact on the
Health/Safety/Welfare
of any person
affected: e.g.
Patient/Service User,
Staff, Visitor,
Contractor)
 Near miss, no injury or
harm.
INFORMATION
 Minor loss of nonpersonal information.
IMPACT (CONSEQUENCE) LEVELS [can be used for both actual and potential]
MINOR (2)
MODERATE (3)
MAJOR (4)
 Short-term injury/minor harm
requiring first aid/medical
treatment.
 Minimal injury requiring no/
minimal intervention.
 Non-permanent harm lasting
less than one month (1-4 day
extended stay).
 Emotional distress (recovery
expected within days or
weeks).
 Increased patient monitoring
 Loss of information.
 Semi-permanent harm/disability 
(physical/emotional
injuries/trauma) (Recovery
expected within one year).
 Increase in length of hospital

stay/care provision by 5-14 days.
 Loss of or unauthorised access
to sensitive / business critical
information
Long-term permanent
harm/disability
(physical/emotional
injuries/trauma).
Increase in length of hospital
stay/care provision by >14
days.
 Loss of or corruption of
sensitive / business critical
information.
CATASTROPHIC (5)


Permanent harm/disability
(physical/ emotional trauma) to
more than one person.
Incident leading to death.
 Permanent loss of or corruption
of sensitive/business critical
information.
*PLEASE NOTE THAT THIS INFORMATION WILL BE TREATED ANONYMOUSLY AND WILL NOT BE USED FOR ANY PURPOSE OTHER THAN
LEARNING.
Please post completed document to:
Medicines Governance Adviser, Integrated Care, Local HSCB Office