Pharmacy Incident Report
East Kent Drug & Alcohol Service
Document Title
Submission Date
/
Day
/
Month
Year
Email Address Sender FT
No Reply Email
Please select your local Forward Trust service?
*
Please Select
Ashford
Canterbury
Dover & Folkestone
Swale
Thanet
Back
Next
Incident Reporter Information
Name
*
First Name
Last Name
Role
*
Email
example@example.com
Telephone Number
Back
Next
Pharmacy Information
Pharmacy Name
*
Address
*
Street Address
Street Address Line 2
Town
County
Post Code
Telephone Number
*
Please enter a valid phone number.
Pharmacy NHS Email
*
example@nhs.net
Back
Next
Incident Information
Incident Date & Time
*
/
Day
/
Month
Year
Minutes
AM
PM
AM/PM Option
Where did the incident occur?
*
What exactly happened?
*
What immediate action(s) was taken following the incident?
*
Degree of harm caused to individual?
*
Please Select
Near Miss
No Harm
Low
Moderate
Severe
Death
What were the contributing factors to the incident?
*
Has any action been taken or planned to prevent a recurrence?
*
In your view, what were the underlying causes or events which led to this incident?
*
What further action or support is needed to resolve this incident?
*
Please provide any further comments or information here.
Back
Next
Affected Individual Information
Name
*
First Name
Last Name
Date of Birth
/
Day
/
Month
Year
Date
Address
Street Address
Street Address Line 2
Town
County
Post Code
Submit
Should be Empty: