Shropshire & Staffordshire Area Team

Confidential

THIS FORM MUST BE COMPLETED AS SOON AS AN INCIDENT HAS OCCURRED AND FORWARDED TO THE ACCOUNTABLE OFFICER

CONTROLLED DRUGS INCIDENT REPORTING FORM

Please complete all sections

“Procedures should be put in place to alert the Accountable Officer of any complaints or concerns involving the management and use of CDs.”

Date of Incident: / Date of Notification:
Reporting Pharmacy/ Dentist/ Care Homes
Name:
Address: / Service/GP Surgery involved
Reported By:
Position:
Telephone: / Other Persons Involved:
Position:
Telephone:
Incident Type (Please tick)
Dispensing Error Prescriber/ Prescribing Error Other (Give details)……...... …..…………
If the incident is an unresolved stock balance please complete the Unresolved CD discrepancies Form
Please provide a detailed description of incident
This section must be legible and provide a detailed account of the incident:
-What happened?
-Who was involved?
-What medication was being dispensed/prescribed?
-Quantities of medication?
-Any other information that would help others to learn from the incident.
-Continue on a separate sheet if necessary

CONTROLLED DRUGS INCIDENT REPORTING FORM

Immediate action taken:
What measures have been put in place to prevent any recurrence of this incident? (continue overleaf if necessary)
Provide details of what action was taken following the incident:
-What immediate action was taken?
-Was the patient contacted?
-Where there any adverse effects to the patient, what action was taken if there was?
-If necessary, has the prescriber been informed?
-Who has been informed of the incident?
Who has been notified of this incident(Please tick all that apply)
PolicePatient Prescriber NPSA Superintendent Pharmacist
Other Please Specify______
If the Superintendent Pharmacist has been notified please provide their name and contact details.
Name: ______Telephone Number: ______
Email Address: ______

Signature: Date: .

Important Notice Regarding Controlled Drugs Incident Reporting:

All incidents must be reported to the Accountable Officer for Shropshire and Staffordshire Area Team at the time of the incident taking place via this form.

Where there is an investigation being undertaken following areported incident, a follow-up report will be required to be completed and submitted regarding the incident.

This report must be received within 28 days of the incident being reported and should be returned with a copy of any internal investigation reports that have been undertaken.

Please return by email to r by post marked “Confidential -for the attention of Eleanor Carnegie, Controlled Drugs Support Officer, NHS England, Shropshire & Staffordshire Area Team, Anglesey House, Wheelhouse Road, Towers Plaza, Rugeley, WS15 1UL

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