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Incident report form


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

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. Look for a similar diagram at the top of each page to check your progress.

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

Start reporting here...

Get Help on this question
In which service did the Patient Safety Incident occur? (This may not be the same as the service in which you work)
      Start a new Patient Safety Incident Report

Open an existing partially completed Patient Safety Incident Report

An image containing a number sequence used to open existing reports What is this?

Write the numbers in the image here :

AND your existing ReportID :

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.