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The form contains required questions that must be completed in order to submit any Patient Safety Reporting Program (PSRP) 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 . The system will automatically save a partially completed form report regardless of whether the required fields are completed.
The following questions are required for any adverse event PSRP 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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When was the DNS or administrator notified of the event?
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Corporation
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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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Level of care
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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/resident factors?
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Were there any contributing patient/resident 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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Did the review and analysis team have a post-analysis briefing with the interdisciplinary team?
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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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Event Summary, Causes, and Action Plans
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Harm Category
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Event Details
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Contributing Factors
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Event Review and Analysis
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