Event Report Form

Use this form to report either a patient safety event or unsafe condition. The term “unsafe condition” includes unsafe staffing and/or any condition that is unsafe to patients, employees, or visitors. The term “event” includes both an incident that reaches the patient and a near miss that did not. You can submit this form Anonymously by checking “Anonymous Reporter” box, or, if you wish you can type your name and other info at the end of this form. Due to HIPAA Regulations, DO NOT ENTER Patient’s private information including name, address, DOB, SS#, Medical Record #, etc.

1. What is being reported? CHECK ONE: (required)

Incident: A patient safety event that reached the patient, whether or not the patient was harmed.

Near Miss: A patient safety event that did not reach the patient.

Unsafe Condition: Any circumstance that increases the probability of a patient safety event.

2. Was there any evidence of harm to a patient at the time of this report? CHECK ONE: (required)

Yes

Unknown

3. Event Discovery Date

Unknown

4. Event Discovery Time:

Unknown

5. Briefly describe the event that occurred or unsafe condition: (required)

6. Briefly describe the location where the event occurred or where the unsafe condition exists: (required)

Type your service area (unit), Room/Bed #, etc.

8. How many patients were affected? ENTER NUMBER: (required)

In case of unsafe staffing type the number of all patients under your, or your unit's care because unsafe staffing affects all patients.

9. Report Date: (required)

10. Check this Box if you wish to remain Anonymous

Anonymous Reporter

11. Reporter’s Name:

Optional

12. Reporter's Telephone Number:

Optional

13. Reporter's Email address

Optional

14. Reporter’s Job or Position:

Optional

This field should be left blank

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