Patient Safety Incident Report

Anaesthesia report form

Introduction

This form should be used to report any unintended or unexpected anaesthesia related incidents which could have or did lead to harm for one or more patients receiving NHS-funded health care that occurred:

Anytime during the surgical patient pathway

During a planned anaesthesia for a diagnostic or surgical intervention.

When the incident report is submitted to NPSA, your risk manager gets notified automatically and a summary of the incident report is sent to enable local follow up if required.

Please do not include personal identifiable information in your incident report including staff, patient, carer or relative names or addresses and patient hospital numbers.

Please refer to the Help section for further information about how to complete this form, who to contact for assistance and when incidents should also be reported to other organisations e.g. Medicines and Healthcare products Regulatory Agency (MHRA). Further information about how the NPSA will use you incident report is available on our website.

Pages to expect

The diagram below shows the pages you may encounter depending on the incident you are reporting.

An image of a progress bar giving an example of how progress is fedback to the user.

This incident report form ("eForm") has been developed by the National Patient Safety Agency ("NPSA") to help report patient safety incidents. The use of the eForm by you is subject to Terms and Conditions of Use which you are deemed to have accepted if you use the eForm.

Anaesthesia report form

Introduction

Pages to expect

Open an existing partially completed Patient Safety Incident report