Adult Critical Care Transfer Adverse Incident Reporting:

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Please report a Transfer adverse incident as per your Trust Clinical Incident Report
process (e.g. Datix).

This does not replace Trust incident reporting but the additional
feedback will allow us to learn and support quality improvements with the
commissioning of transfer service. NO PATIENT IDENTIFIABLE DATA IS REQUIRED.

Please briefly explain using an SBAR approach to the transfer incident. This should only take a few minutes to complete but will provide valuable learning for the transfer service. Thank you

1. Name of reporting hospital/ICU? *

2. Date of adverse incident *

YYYY

3. Contact person for any follow up:

4. If Datix completed, please provide Datix number:

5.Please select Degree of harm (severity/actual impact on patient) *

No harm (near miss)

Low (minimal harm - patient required extra observation or minor treatment)

Moderate (short term harm- patient required further treatment/procedure)

Severe (Permanent or long-term harm)

Death (caused by the patient safety incident)

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