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
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
Are there any staff members involved in the incident who would like to have a debrief with an RLNZ staff member about the incident or to get support? If you select yes, we will arrange a formal debrief for you. Please contact the on-call person if you need immediate support.
Yes
No
Recommended actions by staff member
Name of staff completing the above part of this form?
First Name
Last Name
Submit
Should be Empty: