Anonymous Reporting of Adverse Incidents by Community Pharmacy Services

You have chosen to report this information to us in an anonymous way and therefore we cannot identify the sender or any of the individuals involved in the incident. To preserve this anonymity, please do not include any information that will identify patients or pharmacy staff*.
If you want to report a ‘named’ incident, please contact a member of the Primary Care Medicines Governance Team. If the incident involves a Controlled Drug, the Accountable Officer (HSCB) and Pharmacy Inspectorate Medicines Regulatory Group, Department of Health NI, must be notified as soon as possible without compromising the steps needed to ensure patient safety.
* HSCB reserves the right to edit/remove information received eg inclusion of person-identifiable information.

Questions marked with asterisk * must be completed

Date of Incident*
Approximate date if exact unknown
Age of Patient involved in incident
Approximate age if exact unknown
Summary of incident*
(Must not include information that will identify patients or staff)
Tell us the story of what went wrong or could have gone wrong, and how the incident was discovered. Include relevant information regarding the incident together with name, form, dose and quantity of medications prescribed and same for those dispensed (if different), whether the patient actually received or consumed the medication and any harm that occurred. For product-specific concerns (e.g labelling and packaging risks), please include the manufacturer name and product batch number.
Was any harm caused ?*
- No
- Yes
Possible causes or contributory factors*
Action taken by pharmacy to prevent a re-occurrence*
Further recommendations to prevent a re-occurrence
Thank you for reporting your incident to the HSCB Anonymous Incident Reporting System. The information that you have provided will be used by the HSCB to share learning with healthcare professionals across Northern Ireland or with suppliers/other health organisations where this will contribute to the safer use of medicines.

If you wish to print or save a copy of your report for your records, please do so BEFORE submitting. The report will not be accessible to pharmacy staff to print once submitted.
Name
This field is for validation purposes and should be left unchanged.