Form 57.106 Patient Safety Monthly Reporting Plan

* required for saving  Facility ID:_______________________		*Month/Year:______ /______
 No NHSN Patient Safety Modules Followed this Month
Device-Associated Module
Locations ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________	CLA BSI          		DE          	VAP          	CAUTI          	CLIP          
Procedure-Associated Module
Procedures ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________	SSI (Circle one setting) In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both			Post-procedure PNEU (Circle) In In In In In In In In In In
Medication-Associated Module: Antimicrobial Use and Resistance
Locations ___________________ ___________________ ___________________ ___________________ ___________________	Antimicrobial Use     			Antimicrobial Resistance     

 

MDRO and CDI Module

+Locations (Circle one) FacWideIN   FacWideOUT FacWideIN   FacWideOUT FacWideIN   FacWideOUT FacWideIN   FacWideOUT

Specific     Organism Type ________ ________ ________ ________

±LabID Event All specimens    

±LabID Event Blood specimens only                                    

Process and Outcome Measures

Locations

Specific         Infection Organism    Surveillance Type

§AST Timing

§AST  Eligible

Inci- dence

Preva-lence

Lab ID Event

HH

GG

______

________         

Adm Both

All NHx











_______

________         

Adm   Both

All   NHx











_______

________         

Adm   Both

All NHx











_______

________         

Adm Both

All NHx











_______

________         

Adm Both

All   NHx











Vaccination Module

Check one:

Summary Method



Patient-level Method



+ FacWideIN= Facility-wide Inpatient   FacWideOUT =Facility-wide Outpatient ±LabID Event – Laboratory-identified Event §For AST, circle one choice to indicate timing of testing and one choice to indicate type of patients eligible for testing. Timing: Adm = Admission      Both = Both Admission and Discharge/Transfer

Patients Eligible: All = All patients tested

NHx = Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission.

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-08-03
File Created	2004-07-27

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