The Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland
Perfusion Report Form

Web Report Form

Date of report    
   
Name of person reporting incident    
   
Position    
   
Hospital Name    
   
Full address (including postcode)    
   
Telephone Number    
   
e-mail address for correspondence    
   
Date of Incident    
   
Local reference number    
   
Consultant in charge    
   
Type of device    
   
Model    
   
Manufacturers name    
   
Catalogue number (if standard item)    
   
Serial number    
   
Lot or Batch Number    
   
Date of manufacture (if known)    
   
Expiry date    
   
Current location of the device    
   
Has the manufacturer/supplier been contacted?    
   
Is the device CE marked?    
   
Any resulting injury?    
Serious Moderate Minor None  
Agencies informed (tick all that apply)    
MHRA NPSA NICE Local Risk Group
Details of incident/Nature of defect    
   
Details of injury (to patient/healthcare professional)    
   
Action taken (includes any action by patient, carer or healthcare professional, or by the manufacturer or supplier
   
We would like to publish interesting reports to keep the membership informed. Are you are happy to have your anonymized report published on the Safety Committee webpage?