General Information

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  Age unit (ASC, Nursing Facility, Pharmacy)
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  Contact email address
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  Contact extension
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  Contact name
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  Contact phone
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  Date discovered
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  Event date
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  Event time
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  Event time unknown
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  Form ID
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  Last modified date
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  Patient age
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  Patient ethnicity
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  Patient gender (ASC, Hospital, Nursing Facility)
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  Patient race
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  Select your facility (Nursing Facility)
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  Submission date
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  When was the DNS or administrator notified of the event?
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  Who should we contact for clarification or feedback?

Harm Category

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  Did an actual adverse event occur?
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  Did the event contribute to or result in patient death?
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  Did the event reach the patient?
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  Did the event require any of the following significant interventions? (Nursing Facility)
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  The Harm Category for this event is
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  Was an intervention necessary to sustain life required?
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  Was extra monitoring or an intervention to preclude harm required?
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  Was the harm permanent?
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  Was the harm temporary?
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  Was the patient harmed?
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  What prevented the event from reaching the patient? (ASC, Hospital, Nursing Facility)
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  What was the extent of harm to the patient?
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  Which intervention to preclude harm was required? (Hospital and Nursing Facility)

Event Information

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  Event location (Nursing Facility)
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  Event type (Nursing Facility)
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  How preventable was the incident?
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  Level of care
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  Relevant comorbidities
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  Relevant surgeries or procedures

Event Type-Specific Questions

Device, Equipment or Supply Event-Specific Questions

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  Specific device
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  Type of device or supply involved (Nursing Facility)
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  Which best describes the event?

Fall Event-Specific Questions

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  Date of most recent fall risk assessment
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  Did any physical device contribute to the fall?
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  Did the patient/resident sustain a physical injury as a result of the fall? (Nursing Facility)
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  Prior to the fall, what was the patient doing or trying to do? (Nursing Facility)
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  Was a fall risk assessment documented?
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  Was the fall assisted or unassisted?
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  Was the fall observed? (Nursing Facility)
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  Was the medication considered to have contributed to the fall?
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  Was the patient/resident assessed to be at any level of risk for a fall? (Nursing Facility)
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  Was the patient/resident on medication known to increase fall risk at the time of the fall? (Nursing Facility)
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  Were any of the following risk factors considered to have CONTRIBUTED to the fall?
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  Were any of the following risk factors present at the time of the fall?
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  What type of injury was sustained?
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  What was the patient/resident’s goal? (Nursing Facility)
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  What was the physical or environmental cause of the fall?
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  Which of the following were in place and being used to prevent falls for this patient/resident? (Nursing Facility)
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  Which of the following were in the patient’s care plan to prevent falls? (Nursing Facility)
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  Why was the most recent fall risk assessment performed? (Nursing Facility)

HAI Event-Specific Questions

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  Type of central line involved
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  Type of healthcare-associated infection (HAI) (Nursing Facility)
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  Type of pathogen
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  Was the infection determined to be present or incubating on admission?

Medication or Other Substance Event-Specific Questions

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  At what stage in the process did the event originate, regardless of the stage at which it was discovered? (ASC, Hospital, Nursing Facility)
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  Generic name or investigational drug name
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  Type of medication or other substance event (ASC, Hospital, Nursing Facility)
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  Type of other substance (Nursing Facility)
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  Was this medication/substance given to this patient?
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  Was this medication/substance prescribed for this patient?
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  Were any of the following involved? (Nursing Facility)
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  What type of medication/substance was involved? (ASC, Hospital, Nursing Facility)
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  What was the actual route of administration? (Nursing Facility)
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  What was the contraindication (potential or actual interaction)?
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  What was the intended route of administration? (Nursing Facility)

Pressure Injury Event-Specific Questions

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  Most advanced stage of pressure injury being reported
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  On admission to the facility, was a skin inspection documented?
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  Pressure injury location on the body
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  Type of risk assessment performed
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  Was any preventive intervention implemented?
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  Was the patient/resident assessed to be at any level of risk for a pressure injury?
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  Was the use of a device or appliance involved in the development or advancement of the pressure injury?
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  What was the stage of the pressure injury on admission?
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  What was the type of device or appliance? (Nursing Facility)
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  When was the first pressure injury risk assessment documented?

Contributing Factors

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  Communication factors (Nursing Facility)
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  Contributing Factor Category: Communication
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  Contributing Factor Category: Device, Equipment, or Supply
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  Contributing Factor Category: Human or Environmental
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  Contributing Factor Category: Organizational
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  Contributing Factor Category: Patient/Resident (Nursing Facility)
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  Contributing Factor Category: Patient/Resident Management (Nursing Facility)
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  Contributing Factor Category: Policy or Procedure
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  Device, equipment, or supply factors (Nursing Facility)
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  Human or environmental factors (ASC, Hospital, Nursing Facility)
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  Organizational factors (Nursing Facility)
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  Patient/Resident factors (Nursing Facility)
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  Patient/resident management factors (Nursing Facility)
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  Policy or procedure factors (ASC, Hospital, Nursing Facility)

Review and Analysis Information

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  Date review and analysis completed
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  Did the review and analysis team have a post-analysis briefing with the interdisciplinary team? (Nursing Facility)
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  Members of the review and analysis team (Nursing Facilities)
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  Person hours spent in review
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  Please specify why no written notification was given
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  Who was given written notification? (Nursing Facility)
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  Why was your facility unable to provide written notification?

Summary, Cause and Action Plan Information

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  Action plans
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  Causes
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  Event Summary
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  Is this a root cause?