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The form contains required questions that must be completed in order to submit any report. Depending on the event type selected, there may be additional event-specific questions that must be completed prior to submission (see Which events trigger additional event-specific questions?). If needed, you will be able to save a partially completed form regardless of whether the required fields are completed. The following questions are required for any adverse event report:
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Event date
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Event time
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Date event was discovered
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Multi-hospital system
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Facility
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Patient’s gender
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Patient’s age
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Patient’s race
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Patient’s ethnicity
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Facility contact name
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Facility contact email address
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Facility contact phone
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NCC MERP harm category
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Event type
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Event location
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Were there any contributing communication factors?
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Were there any contributing device or supply factors?
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Were there any contributing human or environmental factors?
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Were there any contributing organizational factors?
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Were there any contributing patient factors?
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Were there any contributing patient management factors?
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Were there any contributing policy or procedure factors?
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Date event review and analysis completed
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Members of the event review and analysis team
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Person hours spent in review
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Who was notified of this event at your facility?
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Was a post-analysis briefing done with senior management?
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Was the patient or a patient representative given written notification of this event?
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Complete account of the event
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Cause of the event
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Is this a root cause?
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General Information
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Harm Category
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Event Information
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Contributing Factors
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Review
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Summary
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