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HC NIRF 01 – V09Date issued: 25/01/2017NATIONAL INCIDENT REPORT FORM (NIRF)NIRF - 01 PERSONNIMS record Number:Incident: An event or circumstance which could have, or did lead to unintended and / or unnecessary harm. Please complete this form to the best of your knowledge at the time of reporting the incident.SECTION A: GENERAL INCIDENT DETAILSSECTION B: PERSON AFFECTED DETAILSDate of incidentFirst nameSurnameTime of incidentLocationUse 24 hour clockE.g. Hospital, Health Centre, Residential Centre etc.Specific LocationE.g. Ward, Clients home etc.Date of birthFemaleMaleOffsite?Description of incident:Division (tick one only )Who was involved ? (tick one only )Acute HospitalService user – (Resident/Patient/Client) Go to section CSocial CareStaff member – Go to section DHealth and WellbeingAgency / Panel staff – Go to section DPrimary CareMember of public-Proceed to section FMental HealthVolunteer – Go to section DAmbulance ServiceExternal Contractor – Go to section EStudent – Go to section DSECTION C: SERVICE USER DETAILS ONLYHealthcare Record NoLead ClinicianThis incident involved (tick one only )SECTION D: STAFF MEMBER / AGENCY / PANEL STAFF /STUDENT / VOLUNTEER DETAILS ONLYCategory ofpersonEmployee no.Adolescent SpecialtiesDate absencecommenced(if known)Date returned towork(if known)Adult SpecialtiesWork days lostNeonatal SpecialtiesPaediatric SpecialtiesOlder Person SpecialtiesSECTION E: EXTERNAL CONTRACTOR DETAILS ONLYIncident Occurred under(Service / Specialty)E.g. Antenatal, Audiology,Radiotherapy, Intellectual Disability,PsychologyCompany NameCompany no.Page 1 of 6

SECTION F: WHAT WAS THE OUTCOME AT THE TIME OF THE INCIDENT? OutcomeBody Part AffectedNear MissNear Miss e.g. Nearly given wrong drugNo HarmNo Injury e.g. Wrong drug given but no harm occurredInjury not requiring first aidE.g. Arm, Spine, Lung, Other PhysiologicalInjury or illness, requiring first aidHarmInjury requiring medical treatmentLong-term disability / Incapacity (incl. psychosocial)DeathSECTION G: TYPE OF INJURY (tick one only )Birth Specific Injury(Baby)Birth Specific Injury(Mother)Blood Specific InjuryDiagnosed DiseaseDisorder or Cond.Diagnosed InfectionGeneral InjuriesHearing / Sight InjuryMisdiagnosisMusculoskeletal/ Soft TissuePersonal LossSurgery SpecificInjuryTraumatic/EmotionalHC NIRF-01Apgar score 5@ 1 min &/or;7@5mins &/or pH 7.0AspirationCerebral irritability / neonatalseizureHIE - Hypoxic IschaemicEncephalopathy withHypoglycaemiaHIE Grade 1 - Hypoxic IschaemicEncephalopathyDeathHysterectomy (Perinatal)Incontinence (faecal)Incontinence (urinary)Excessive BleedingFaintingImmunological haemolysisAsbestosisCancerAcute Radiation SyndromeNarcolepsy/CateplexyHIE Grade 2 - Hypoxic IschaemicEncephalopathyHIE Grade 3 - Hypoxic IschaemicEncephalopathyHypoglycaemia - severeKernicterusNeonatal deathNerve Injury - brachial plexus (incl.Erbs Palsy)Nerve Injury - faceOther unexpected deteriorationStillbirthSub-galeal / sub-aponeurotichaemorrhageUnknownOtherPerineal tearPost-Partum HaemorrhageRhesus iso-immunisationIncontinence (faecal & urinary)Febrile non-haemolytic transfusionreactionUnknownUterine nownDermatitisTBPleural PlaquesOtherClostridium DifficleMRSAESBLNorovirusHepatitisUnknownAllergic Reaction (incl. anaphylaxis)Cut / Laceration / Graze / scratchBrain Injury / ConcussionDeathBurn / scald / corrosionDental injury &/or lossChoking / asphyxiaDeteriorationCirculatory / volume depletionHaemorrhageCirculatory / volume overloadBlisterPain/DiscomfortHearing Impairment / lossTinnitusSight Impairment / nFractureBruisingRepetitive Strain Injury (RSI)CrushingSlipped / Prolapsed DiscDental Fracture / Tooth lossSprain / StrainDislocationSoft tissue injuryP. Ulcer Stage 1: Intact skin with non-blanchable redness over bony prominenceP. Ulcer Stage 2: Part thickness dermis loss: blister/open ulcer/no sloughP. Ulcer Stage 3: Full thickness tissue loss: /- visible subcutaneous fatP. Ulcer Stage 4: Full thickness tissue loss/necrosis: exposed bone/tendon/muscleAdditional / Further SurgeryLoss of Wages / Income /Limb DeformityBusinessDefamation of CharacterLoss of ConsortiumDamage to organ / body partLoss of organ / body partDental Damage / LossNerve injury / Loss ofForeign body left in situFunctionUnknownInadequate anaesthesiaAnxiety / TraumaStressPTSDUnknownNon-immunological haemolysisOtherVREVRSAOtherMalaise / NauseaNerve injury / Loss of FunctionPuncture / biteRash / irritationUnknownOtherOtherOtherSwelling / InflammationUnknownWhiplashOtherUnknownOrgan RetentionOtherUnexpected complication /deteriorationOtherWorried WellOtherPage 2 of 6

SECTION H WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, 3 & 4)Step 1.Birth siveNon InvasiveStep 3.Communication / ConsentDiagnosis / AssessmentDocumentation / RecordsEquipmentGeneral Care / ManagementProcedure / Treatment /InterventionScreening / PreventionSpecimens / ResultsTests / InvestigationsUnknownOtherRoute of administrationOralIntravenousSub CutaneousIntra MuscularTopicalRectalInhalationOther / UnknownAdministrationMonitoringOrdering / Supply / TransportPreparation / geClinical CareWhat medication was involved?Medication OneMedication TwoNutritionParenteralEnteralSpecial DietGeneral DietOtherBlood / BloodProductWhole BloodRed CellsPlatelet (Apheresis)Platelets (Pooled)OtherDiagnosticRadiology (DR)& NuclearMedicine (NM)RadiotherapyBio HazardsStep 2.Caesarean Section(Elective)Caesarean Section(Emergency)Instrumental Delivery(Forceps)Instrumental Delivery(Vacuum)Instrumental Delivery(Multiple Instruments)Non InstrumentalDeliveryBiologicalHazards /AcquiredInfectionsHC NIRF-01Checking Patient IDprocedureClinical Details onReferralCommunication /ConsentDocumentation /RecordsEquipmentPerforming procedurePregnancy StatusUnknownBacteriaFungus / MouldPrionVirusOrganism UnknownCommunication / ConsentPrescribing / RequestingPreparation / DispensingAdministrationStorageDocumentation / RecordsEquipmentSupply / Ordering / TransportPresentation / PackagingTransfusing bloodOtherDiagnostic Exposure intendedX-ray Over ExposureWrong body part / sideDose to comforters / carersWrong PatientInadvertent dose to foetusTotal dose or Volume VariationDose (NM) or Volume Variation(1 fraction)Wrong DrugWrong DoseWrong Process / Treatment /InterventionFailure / MalfunctionInadvertent deterministic effectsStep 4.Adverse EffectFailure / MalfunctionForeign Body left in SituInappropriate for Task / Wrong deviceIncomplete / InadequateLack of AvailabilityNot performed when indicated / DelayPre Existing Medical ConditionShoulder DystociaUnavailable / Mislabelled / LostWrong Body Part / Site / SideWrong PatientWrong Process / Treatment / ProcedureOtherAdverse Drug ReactionContra-indicatedDrug InteractionFailure / Malfunction of equipmentIncomplete / InadequateNot preformed when indicated /delayedOmitted/Delayed DoseWrong Dose / StrengthWrong DrugWrong Formulation / RouteWrong FrequencyWrong Label / InstructionsWrong PatientWrong Quantity / DurationAdverse EffectIncomplete / InadequateNot performed when indicated / DelayWrong ConsistencyWrong Diet / Wrong Blood ProductWrong Process / Treatment / ProcedureWrong PatientLack of AvailabilityWrong dispensing label / instructionsInappropriate for task / Wrong deviceOtherAbove Notifiable levelsBelow Notifiable levels 1mSv 1mSv 10%10-20% 20%Exposure to Bite (Human)Exposure to Bite (Insect / Animal)Exposure to Bodily FluidsExposure to Ingestion/Food/WaterExposure to Needle StickExposure to Skin ContactInhalation/AirborneEquipment, Implements, Facilities,Sharps (Non Needle)UnknownOtherPage 3 of 6

SECTION H CNTD: WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2 & 3)Step 1.Behavioural HazardsSelf-InjuriousBehaviourStep 2.IntentionalUnintentionalViolence, Harassmentand AggressionChild AbuseBy a Family Member / RelativeBy a Member of the PublicBy a Peer / StudentBy a PrisonerBy a Service UserBy a Staff MemberAdult AbusePhysical HazardsSlip / Trip / FallNon Mechanical(Incl. Person / Animal)Ergonomics(Incl. manual / luding Fire)FireVibrationElectricalNoiseRadiationHC NIRF-01From HeightFrom Equipment / FurnitureSame Level / GroundOn StairsOn StepsOtherObject / Tools (Non Sharps)Sharps (Non Needle)OtherPersonManual HandlingOtherPatient HandlingRestraint / InterventionCatering equipmentDoor / Gate / BarrierHealthcare EquipmentLifting Equipment / AccessoriesOffice / Business equipmentHotColdPlease SpecifyStep 3.Absconsion / MissingAttempted SuicideBanging Self Against Walls/Furniture/SurfacesHitting Body/Slap/Punch Self incl. Scratching &PickingInappropriate EatingInappropriate TouchingSelf-HarmStripping Clothes in Public AreaSuicideThrowing objectsOtherAggressive towards inanimate objectDiscrimination/Prejudice/RacialIntimidation / ThreatNeglectNon-Compliant / Obstructive / RudePhysical Assault / AbusePhysical HarassmentSexual Assault / AbuseSexual HarassmentUnintentional Aggressive BehaviourBullyingVerbal Assault / AbuseVerbal HarassmentOtherUnknownPre Existing Medical ConditionInadequate supervision gen health / post opObstruction / protruding objectSurface contaminantsRough terrain / irregular surfaceInappropriate equipment useFailure / malfunction of equipmentHorseplayPhysical training / sportWeather ConditionInadequate Lighting / designOtherHuman Use / ErrorObstruction / Protruding ObjectPhysical Training / SportDefective EquipmentUnsafe / Inappropriate systemUnknownTaskLoadWorking EnvironmentIndividual CapabilityOtherLiquid / Food / SteamEquipment / UtensilsAtmosphere / EnvironmentDefective EquipmentHuman Use / ErrorUnknownUnsafe SystemExplosionExposureElectrical Wiring / installationPage 4 of 6

SECTION H CNTD: WHAT TYPE OF HAZARD DID THIS INCIDENT RELATE TO? (Tick one option from Steps 1, 2, & 3)Step 1.Step 2.Chemical HazardsAcid / AlkalineAgri ChemicalsGasOther ChemicalProductsParticulatesPetroleum / SyntheticOil Based ProductsSanitation / CleaningChemicalsToxic MetalsAnimal RemedyArsenicAsbestosBleachCadmiumCarbon DioxideCarbon MonoxideChemical FertilizerCrystalline SilicaDetergentDiesel / KeroseneDisinfectantDrain / Oven CleanerDrugsFungicideGlue / AdhesiveGreaseHerbicideHydrochloric AcidStep 3.InsecticideLeadMetallic DustMotor / Gear / Hydraulic OilNatural GasOrganic DustPaint / Paint ProductPetrolPolishRadonRodenticideSoapSodium HydroxideSolventsSpent / Used Oil ProductSulphuric AcidWrong PatientOtherLack of SupervisionUnknownHuman / User ErrorUnsafe SystemSECTION I: IMMEDIATE ACTIONS TAKENSECTION J: OPEN DISCLOSURE & SERIOUS REPORTABLE EVENT (SRE) DETAIL:Was open disclosure required? (tick one only )YesIs this incident an SRE? (tick one only )NoNoPotentialDate of open disclosure:Time of open disclosure:*As per HSE Guidelines Available @ Open Disclosure*Use 24 hour clock*As per HSE Guidelines Available @ Special Report: Serious ReportableEvents (SREs)*Any further information?HC NIRF-01Page 5 of 6

SECTION K: REPORTED BY: person who discovers the incident and unlessotherwise stated within the organization, this person is responsible for completing the NIRF.First nameSurnameSECTION L: WITNESS DETAILS (Name, Contact No. etc.)Date notifiedCategory of personLocal systemreference no.Reporter Signature:E.g. Nurse, Catering Staff, CleanerDateContact DetailsLine ManagerSignature(where required):DateSECTION M: NotesHC NIRF-01Page 6 of 6

NATIONAL INCIDENT REPORT FORM (NIRF) NIRF -01 PERSON Incident: An event or circumstance which could have, or did lead to unin Page 1 of 6 tended and / or unnecessary harm. Please complete this form to the best of your knowledge at the time of reporting the incident. SECTION A: GENERAL INCIDENT DETAILS Date of incident Time of incident Use 24 .