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Clinical Adverse Event Reporting Form

The ATP collates and records all kinds of adverse or unexpected incident reports. This information is submitted by its members anonymously (also no identifiable patient data is included) so that the facts and the figures can be quantified to benchmark and audit, to identify risk factor potential and probability.

This may include:

All bleeding concerns should be reported that requires management (other than infant feeding to stem bleeding).
Incomplete divisions; both by oneself, or assessed by oneself but original frenulotomy was conducted by another
Adverse or unusual reactions
Infections
Additional medical interventions
Any unusually occurring ‘event’ or anomaly
Complications

This is for ATP monitoring and audit which is separate to a CQC notification.

CQC Notification requirements are listed and submitted on their website through your provider portal:

Notifications - Care Quality Commission (https://www.cqc.org.uk/guidance-providers/notifications)

Clinical Adverse Event Form

Practitioner Name:

Email:

Date of Incident

Venue of Incident

What setting was the infant treated in?

Age of Infant

What 'type' of tongue tie restriction was the infant treated for?

Has the infant received Vitamin K?

Summary of Incident

What immediate action was taken?

Were any other healthcare professionals involved in subsequent care?

What was the initial outcome?

Was the infant transferred to an NHS Hospital?

What was the final outcome?

Please use this space to include any additional information that you feel may be relevant:

Would you like the opportunity for a debrief?

Has a debrief already been completed?

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Please bear with us whilst we process your application. The ATP committee all work as volunteers alongside managing their own working lives and families. We will do our very best to ensure that this service is as swift as it can be. Thank you

Clinical Adverse Event Reporting Form

Clinical Adverse Event Form

Please bear with us whilst we process your application. The ATP committee all work as volunteers alongside managing their own working lives and families. We will do our very best to ensure that this service is as swift as it can be. Thank you

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