This page provides a list of all questions found on the PSRP reporting form for Ambulatory Surgery Centers (ASCs). They are grouped alphabetically by the section of the form in which they appear. This list does not indicate which questions are required for all ASC reports nor which questions only appear for certain event types. A list of required questions can be found here: Required Fields for ASCs.

General Information

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

Summary, Cause and Action Plan Information

• Page:
  Action plans
• Page:
  Causes
• Page:
  Event Summary
• Page:
  Is this a root cause?

Harm Category

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

Event Information

• Page:
  Admitting diagnosis
• Page:
  Event location (ASC)
• Page:
  Event type (ASC)
• Page:
  How preventable was the incident?
• Page:
  Relevant comorbidities
• Page:
  Relevant surgeries or procedures
• Page:
  Was the event associated with HIT (Health Information Technology)?
• Page:
  What was the patient’s documented ASA Class?

HIT Questions

• Page:
  Type of EHR involved
• Page:
  Type of HIT device involved
• Page:
  Was the event associated with HIT (Health Information Technology)?
• Page:
  Which human/device interface or ergonomics issue(s) were involved?
• Page:
  Which of the following describes the circumstances involving the HIT in the event?
• Page:
  Which problem(s) resulted from the HIT function problem?

Event Type-Specific Questions

Anesthesia Event-Specific Questions

• Page:
  Anesthesia event type
• Page:
  Type of airway management problem
• Page:
  Type of physical injury
• Page:
  Was a briefing conducted prior to the induction of anesthesia?

Blood or Blood Product Event-Specific Questions

• Page:
  During which stage did the event originate (regardless of the stage when it was discovered)?
• Page:
  Type of blood product involved
• Page:
  Was an independent double-check documented?
• Page:
  Which best describes the blood or blood product event?

Contaminated Drug, Device or Biologic Event-Specific Questions

• Page:
  Was the event reported to MedWatch?

Device, Equipment or Supply Event-Specific Questions

• Page:
  Specific device
• Page:
  Type of device or supply involved (ASC, Hospital)
• Page:
  Was the event reported to MedWatch?
• Page:
  Which best describes the event?

Fall Event-Specific Questions

• Page:
  Did any physical device contribute to the fall?
• Page:
  Did the patient sustain a physical injury as a result of the fall? (ASC, Hospital)
• Page:
  Prior to the fall, what was the patient doing or trying to do? (ASC)
• Page:
  Was the fall assisted or unassisted?
• Page:
  Was the fall observed? (ASC and Hospital)
• Page:
  Was the medication considered to have contributed to the fall?
• Page:
  Was the patient on medication known to increase fall risk at the time of the fall? (ASC, Hospital)
• Page:
  What type of injury was sustained?
• Page:
  What was the patient’s goal? (ASC, Hospital)
• Page:
  What was the physical or environmental cause of the fall?

HAI Event-Specific Questions

• Page:
  SSI site
• Page:
  Type of central line involved
• Page:
  Type of healthcare-associated infection (HAI) (ASC)
• Page:
  Type of pathogen
• Page:
  Was the infection determined to be present or incubating on admission?

Medication or Other Substance Event-Specific Questions

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

Surgical or Other Invasive Procedure Event-Specific Questions

• Page:
  Number of staff changes (after timeout)
• Page:
  Type of surgical or other invasive procedure event (ASC)
• Page:
  Was a safe surgery/procedure checklist used?
• Page:
  Was the patient’s death directly attributable to the surgery or procedure?

Unintended Retained Foreign Object Event-Specific Questions

• Page:
  Did the surgeon perform a cavity sweep?
• Page:
  Number of staff changes (after timeout)
• Page:
  Type of retained object
• Page:
  Was a safe surgery/procedure checklist used?
• Page:
  Was the patient’s death directly attributable to the surgery or procedure?
• Page:
  Was the retained object identifiable by any of the following means?
• Page:
  Were counts performed for the type of object that was retained?

Contributing Factors

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

Review and Analysis Information

• Page:
  Date review and analysis completed
• Page:
  Did the review and analysis team have a post-analysis briefing with senior management? (ASC, Hospital)
• Page:
  Members of the review and analysis team (ASC)
• Page:
  Person hours spent in review
• Page:
  Please specify why no written notification was given
• Page:
  Who was given written notification? (ASC, Hospital, Pharmacy)
• Page:
  Who was notified of this event? (ASC)
• Page:
  Why was your facility unable to provide written notification?