Remove all [bracketed] and/or red text before publishing! And also the purple note panels!
[Bracketed] text should be replaced with actual content.
Red text is instructional.
Header Case
Title of page and response option headers should be sentence case (to match how they display in the online system).
Other headers in page that aren’t response options should be title case (Description, On-Screen Instructions, etc.).
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Labels
Use form_field and any relevant segment labels (asc, hospital, nursingfacility, pharmacy)
Use the relevant section label (e.g., surgical_event, event_information)
Note: event-specific fields should be tagged with the associated event type (e.g., surgical_event, fall_event) and NOT with overarching header “event_information”)
Use required if the field is required to submit for all reports.
For example, “it is required if it appears” should not be labeled “required.”
Use essential if the field is a top priority for transferring the data dictionary.
Note: if the field is required, it will already be considered “essential” and doesn’t need a second label.
All “essential” labels will need to be removed before the data dictionary goes live.
Description
[Brief description of what this field is collecting]
On-Screen Instructions
[Prompt text as it appears in the user interface.]
Prompt Text
If none or if field does not appear on-screen, put “n/a.” Use “include page” macro where possible (see examples below).
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Description
Determination of which contributing factor(s) related to the organization are known.
On-Screen Instructions
| Include Page | ||||
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Field Type
[Type of field, but really type of interaction user will have: clicking a checkbox or radio button, choosing from a dropdown, filling in a date number, or text field, etc.]Field Type
Use standard language below and delete the others. Use include page macro where possible (see examples, below).
Checkbox (multiselect)
Date (mm/dd/yyyy)
Number (minimum value: x; maximum value: x) [Delete min &/or max values if irrelevant]
Text (maximum length: x) [Delete maximum length if irrelevant]
Time (hh:mm)| Include Page | ||||
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| Include Page | ||||
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| Include Page | Radio button excerpt | Radio button excerpt |
| Anchor | ||||
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OPTION ONE: Answer options with content (definition and/or inclusions, exclusions)
Add an anchor in front of the H1 “Responses” heading and name the anchor “Top.”
Include a table of contents, which should be limited to the answer option headers and displayed as a list.
Add a dividing line macro below the table of contents.| Table of Contents | ||||||
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Answer Option Anchors and Headings
Each answer option gets an anchor and an H2 heading in sentence case.Definition
Copy/paste the “description” text from the data dictionary.
Includes
Excludes
Inclusions and Exclusions
Add a page layout of two equal columns below the definition. Inclusions go in the left column, exclusions in the right.
Event-Type Specific Questions
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Additional Support
| Filter by label (Content by label) | ||||||||
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Event-Type Specific Questions
If the answer option triggers additional question, add a content by label macro to display all pages that share the form_field label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. The macro goes in a single cell table with a light gray fill. The title above the macro should just be table text, bold (no header level), that reads: Event-Type Specific Questions.
Additional Support
If the answer option is associated with an “faq” item, add a second row to the table and paste in a content by label macro to display all pages that share the faq label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Additional Support” in the table cell, above it, as with the “Event specific questions” macro.
Return to Top Links
Below the page layout or Content by Label macro(s) (if relevant), include a link to the “top”anchor to take the user back to the responsestable of content.Dividing Line
Add a dividing line after the “return to top” link and before the next answer option, or the next section (probably “Guide for Use”).
OPTION TWO: Answer options without content
Just list the available answer options without the answerID and answerCode.
[Answer option 1]
[Answer option 2]
[Answer option 3]
Guide for Use
[If there is a adequate information about each answer option, this section may not be necessary. But if there is guidance that isn’t about the specific responses, then this is where you would put it, including instructions for how to use this field. If there is no guidance, you can use the “No additional guidance” excerpt: ]
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An inadequate budget contributed to the event.
Includes
Unit budget
Facility budget
Excludes
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| Anchor | ||||
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Conditions related to staff assignment or work allocation contributed to the event.
Includes
Delegation of task or care to inadequately prepared staff;
Inappropriate staff assignment;
Staff assigned to the wrong unit or patient;
Temporarily assigned internal facility staff (e.g., relief, float, resource, travelers)
Excludes
Lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”)
Inadequate or disproportionate staffing levels (select “Staffing levels”)
Chronic or acute staffing problems (select “Staffing levels”)
Insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”)
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Ineffective supervision during or related to clinical processes contributed to the event.
Includes
Inadequate supervision during learning process (e.g., walking away from a resident preforming their second central line);
Inadequate supervision according to facility policy (e.g., anesthesiologist fails to supervise a CRNA according to policy)
Excludes
Supervision of non-clinical processes (select “Managerial supervision”)
Inadequate staff competencies (select “Staff competencies”)
Tasks performed by untrained or inadequately trained staff (select “Job orientation or training”)
| Anchor | ||||
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The facility’s culture of safety (or lack thereof) contributed to the event.
Includes
Lack of acknowledgment of the high-risk nature of an organization's activities
An environment where individuals are unable to report adverse events or near misses without fear of reprimand or punishment
Collaboration across ranks is not encouraged to seek solution to patient safety problems
Lack of organizational commitment of resources to address safety concerns
Behavior or behaviors from providers or staff that undermine a culture of safety, including overt actions such as verbal outbursts and physical threats, as well as passive activities, such as refusing to perform tasks or uncooperative attitudes (e.g., reluctance or refusal to answer questions, return phone calls or pages, condescending language, impatience with questions or consistently arriving late without regard to team or patient)
Excludes
| Include Page | ||||
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| Anchor | ||||
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Facility’s internal system for reporting adverse events or unsafe conditions contributed to the event.
Includes
Staff did not know how to make an internal report, or what should be reported
Internal reporting is not consistent
Excludes
Facility does not have an internal incident reporting system, or does not analyze internal reports to identify areas of risk (select “Systems to identify risk”)
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The inadequacy of the facility’s job orientation or training contributed to the event.
Includes
Routine job training
In-service education
Competency training
Job orientation
Availability of training programs
Excludes
Lack of staff understanding, technical skill, clinical knowledge (select “Staff competencies”)
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Ineffective supervision during or related to non-clinical processes contributed to the event.
Includes
General manager supervisory functions (e.g., attendance, accountability)
Excludes
Supervision related to clinical processes (e.g., inadequate supervision during learning process or according to facility policy) (select “Clinical supervision”)
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Ineffective or inadequate management or leadership skills contributed to the event.
Includes
Inaction around staff accountability
Lack of knowledge of staff competencies, follow-through
Inadequate skills in motivation, change, supervision
Excludes
| Include Page | ||||
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In Option 2, this is where one would put an “Additional Support” or “Event-type Specific Questions” Content by Label macro in a single-cell table with light gray fill.
If the page should include “additional support” content that is is only relevant to this one question, move the content into the guide for use. If there are multiple pages for the question because of differences between segments, leave the content in a separate page and use the “include page” macro to include it (so we only have to edit in one place but it will still appear in multiple places).
Additional Support
| Filter by label (Content by label) | ||||||||
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History
Start Date
| Anchor | ||||
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Inadequate staff competencies contributed to the event.
Includes
Lack of staff understanding, technical skill, clinical knowledge
Staff familiar with policy or procedure, but performed procedure incorrectly
Excludes
Competency training (select “Job orientation or training”)
Delegation of task or care to inadequately prepared staff (select “Assignment or work allocation”)
Inappropriate staff assignment (select “Assignment or work allocation”)
Staff assigned to the wrong unit or patient (select “Assignment or work allocation”)
Includes
Inadequate or disproportionate staffing levels
Chronic or acute staffing problems
Inadequate or insufficient numbers and/or types of staff for patient care needs
Excludes
Inappropriate staff assignment (select “Assignment or work allocation”)
| Anchor | ||||
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Inadequate systems to identify risk in the facility contributed to the event.
Includes
Facility does not have an internal incident reporting system
Internal reports are not analyzed to identify areas of risk
No system in place to identify areas of risk that have not already resulted in an adverse event or harm to a patient
Excludes
Staff were unaware of how to make an internal report, or what should be reported (select “Internal reporting”)
| Anchor | ||||
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Conditions related to the use of temporary staff contributed to the event.
Includes
Agency or independent staff filling a short-term position or a vacant shift
Excludes
Temporarily assigned internal facility staff (e.g., relief, float, resource, travelers) (select “Assignment or work allocation”)
Delegation of task or care to inadequately prepared staff (select “Assignment or work allocation”)
Inappropriate staff assignment (select “Assignment or work allocation”)
Staff assigned to the wrong unit or patient (select “Assignment or work allocation”)
Inadequate staffing levels, chronic or acute staffing problems, inadequate or insufficient numbers and/or types of staff for patient care needs (select “Staffing levels”)
New staff was not adequately trained or oriented (select “Job orientation or training”)
Other (please describe)
Any other factor related to organizational factors, not included in the list above, which contributed to the event.
Guide for Use
| Include Page | ||||
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History
Start Date | 2006 |
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End Date | n/a |
Change History |
n/a [Month yyyy: brief description of change]
Spring 2012: PSRP implementation |
Field Name | cf_org_f |
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