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Version	Old Version 10	New Version 11
Changes made by	Sydney Edlund	Sydney Edlund
Saved on	Sept 29, 2022	Sept 29, 2022

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Which fields on the form must be filled out in order to submit an ambulatory surgery center report?

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:

Event date
Event time
Date event was discovered
Facility
Patient’s gender
Patient’s age
Patient’s race
Patient’s ethnicity
Facility contact name
Facility contact email address
Facility contact phone

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NCC MERP harm category

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Event type
Event location
Relevant surgeries or procedures
Documented ASA class

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Were there any contributing communication factors?
Were there any contributing device or supply factors?
Were there any contributing human or environmental factors?
Were there any contributing organizational factors?
Were there any contributing patient factors?
Were there any contributing patient management factors?
Were there any contributing policy or procedure factors?

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Date event review and analysis completed
Members of the event review and analysis team
Person hours spent in review
Who was notified of this event at your facility?
Was a post-analysis briefing done with senior management?
Was the patient or a patient representative given written notification of this event?

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Complete account of the event
Cause of the event
Is this a root cause?
Action plan to prevent future event

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Page Properties

hidden	true

Initial Build

Status

colour	Green
title	done

SE 8/6/2021

Staff Review

Status

colour	Blue
title	ready

Comms Approval