Red Book: Near Miss Report
Date of Near Miss
-
Day
-
Month
Year
Date
Time of Near Miss
Hour Minutes
AM
PM
AM/PM Option
Person involved in Near Miss (that would have been harmed) was a:
Staff
Client
Other
Client/Staff/Others Involved
Client was on level:
Please Select
Level 1
Level 2
Level 3
Level 4
Day programme
Number of weeks in treatment
Describe the near miss:
Had the near miss happened, what would have been the maximum impact/injury/illness for the person?
What is the likelihood of harm occurring if this event happened again?
1 - Unlikely
2- Possible
3 - Likely
4 - Very Likely
Severity of event, should it occur (check whiteboard for severity scale)
1 - Minor
2 - Moderate
3 - Major
4 - Critical
Total Risk Assessment Rating (likelihood x severity)
Please Select
1 - 2 Low Risk
3 - 4 Moderate Risk
6 - 9 High Risk
12 - 16 Extreme Risk
Were there any 'lemons' surrounding this event? (ie causative factors that could have been avoided)
Yes
No
Describe the lemons surrounding this event (eg. client was wearing socks):
Recommended actions
Recommended actions by staff member
Name of staff completing the above part of this form?
First Name
Last Name
Submit
Should be Empty: