Form #7 Form #7 Common Formats Complete Set of Forms

Patient Safety Organization Certification Forms and Patient Safety Confidentiality Complaint Form

Attachment K -- Common Formats Complete Set of Forms

Common Formats

OMB: 0935-0143

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0143 can be found here:

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AHRQ Common Formats for
Hospitals
Forms

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

HEALTHCARE EVENT REPORTING FORM (HERF)
Use this form to report either a patient safety event or unsafe condition. The term event includes both an incident that
reaches the patient and a near miss that did not. Highlighted fields are collected for local facility and PSO use. This
information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. What is being reported? CHECK ONE:

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

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

a.
b.
c.
b.
c.

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.

Yes
No
Unknown

3. Event Discovery Date:

___ ___

/ ___ ___ / ___ ___ ___ ___

YYYY

Unknown
4. Event Discovery Time:

Unknown

___ ___ ___ ___
H

HOURS

H
M
M
(MILITARY TIME)

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

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

7. Which of the following categories are associated with the event or unsafe condition? CHECK ALL THAT APPLY:
FOR EACH CATEGORY SELECTED BELOW, EXCEPT “OTHER”, PLEASE COMPLETE THE CORRESPONDING CATEGORY-SPECIFIC FORM. ALL
CATEGORIES INCLUDE REPORTING OF INCIDENTS. ANY CATEGORY WITH + ALSO INCLUDES REPORTING OF NEAR MISSES. ANY
CATEGORY WITH * ALSO INCLUDES REPORTING OF UNSAFE CONDITIONS.

a.
b.
c.
d.
e.

Blood or Blood Product*+
Device or Medical/Surgical Supply*+
Fall
Healthcare-associated Infection
Medication or Other Substance*+

f.
g.
h.
i.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 2

Perinatal
Pressure Ulcer
Surgery or Anesthesia (includes invasive procedure)+
Other*+: PLEASE SPECIFY
________________________________________

Healthcare Event Reporting Form (HERF)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

PATIENT INFORMATION (COMPLETE ONLY IF INCIDENT):
Please complete the patient identifiers below. Additional patient information is captured on the Patient Information Form
(PIF). (When reporting a perinatal incident that affected a mother and a neonate, please complete the patient identifiers
below for the mother (Q8 – Q12) and the neonate (Q13 – Q16). Please also complete a separate PIF for the neonate
involved.)
8. How many patients did the incident reach?
ENTER NUMBER

9. Patient’s Name:
FIRST

MIDDLE

LAST

10. Patient’s Date of Birth: __ __ / __ __ / __ __ __ __ 11. Medical Record #:
MM

12. Patient’s Gender:

Male

YYYY

Female

Unknown

NEONATAL PATIENT INFORMATION (COMPLETE ONLY FOR NEONATE AFFECTED BY PERINATAL INCIDENT):
13. Patient’s Name:
FIRST

MIDDLE

LAST

14. Patient’s Date of Birth: __ __ / __ __ / __ __ __ __ 15. Medical Record #:
MM

16. Patient’s Gender:

Male

YYYY

Female

Unknown

REPORT AND EVENT REPORTER INFORMATION
17. Report Date: ___ ___

/ ___ ___ / ___ ___ ___ ___

18.

Anonymous Reporter

YYYY

19. Reporter’s Name:
FIRST

20. Telephone Number:

MIDDLE

LAST

21. Email Address:

22. Reporter’s Job or Position:

Thank you for completing these questions.
OMB No. 0935-0143
Exp. Date 8/31/2011
Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ
Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD
20850.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 2

Healthcare Event Reporting Form (HERF)

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

PATIENT INFORMATION FORM (PIF)
Use this form only if you are reporting an incident. (When reporting a perinatal incident that affected a mother and a
neonate, complete a PIF for the mother and a separate PIF for the neonate.) Highlighted fields are collected for local
facility and PSO use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. At the time of the event what was the patient’s age? CHECK ONE:

a.
b.
c.
d.
e.

Neonate (0-28 days)
Infant (>28 days <1 year)
Child (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)

f.
g.
h.
i.

Mature adult (65-74 years)
Older adult (75-84 years)
Aged adult (85+ years)
Unknown

e.
f.
g.

White
More than one race
Unknown

2. Is the patient’s ethnicity Hispanic or Latino? CHECK ONE:

a.
b.
c.

Hispanic or Latino
Not Hispanic or Latino
Unknown

3. What is the patient’s race? CHECK ONE:

a.
b.
c.
d.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander

4. Enter the patient’s ICD-9-CM principal diagnosis code at
discharge (if available):
ICD-9-CM CODE

5. After discovery of the incident, what was the extent of harm to the patient (i.e., extent to which the patient’s
functional ability is expected to be impaired subsequent to the incident and any attempts to minimize adverse
consequences)? CHECK FIRST APPLICABLE:

AHRQ’s Harm Scale
Death: Dead at time of assessment.
a.
Severe permanent harm: Severe lifelong bodily or psychological injury or disfigurement that interferes
b.
significantly with functional ability or quality of life. Prognosis at time of assessment.
Permanent harm: Lifelong bodily or psychological injury or increased susceptibility to disease. Prognosis at
c.
time of assessment.
d.
Temporary harm: Bodily or psychological injury, but likely not permanent. Prognosis at time of assessment.
Additional treatment: Injury limited to additional intervention during admission or encounter and/or
e.
increased length of stay, but no other injury. Treatment since discovery, and/or expected treatment in future
as a direct result of event.
Emotional distress or inconvenience: Mild and transient anxiety or pain or physical discomfort, but without
f.
the need for additional treatment other than monitoring (such as by observation; physical examination;
laboratory testing, including phlebotomy; and/or imaging studies). Distress/inconvenience since discovery,
and/or expected in future as a direct result of event.
No harm: Event reached patient, but no harm was evident.
g.
Unknown
h.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 2

Patient Information Form (PIF)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

6. Approximately when after discovery of the incident was harm assessed? CHECK ONE:

a.
b.
c.
d.

Within 24 hours
After 24 hours but before 3 days
Three days or later
Unknown

7. Was any intervention attempted in order to “rescue” the patient (i.e., to prevent, to minimize, or to reverse harm)?
CHECK ONE:

a.
b.
c.

8. Which of the following interventions (rescue) were performed?
CHECK ALL THAT APPLY:

Yes
No
Unknown

a.
b.
c.
d.
e.
f.
g.
h.
i.

Transfer, including transfer to a higher level care area within facility,
transfer to another facility, or hospital admission (from outpatient)
Monitoring, including observation, physiological examination, laboratory
testing, phlebotomy, and/or imaging studies
Medication therapy, including administration of antidote, change in
pre-incident dose or route
Surgical intervention
Respiratory support (e.g., ventilation, tracheotomy)
Blood transfusion
Counseling or psychotherapy
Unknown
Other intervention: PLEASE SPECIFY ____________________________

9. Did, or will, the incident result in an increased length of stay? CHECK ONE:

a.
b.
c.

Yes
No (or not anticipated)
Unknown

10. After the discovery of the incident, was the patient, patient’s family, or guardian notified? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

Thank you for completing these questions.
OMB No. 0935-0143
Exp. Date 8/31/2011
Public reporting burden for the collection of information is estimated to average 15 minutes per response. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ
Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD
20850.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 2

Patient Information Form (PIF)

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

SUMMARY OF INITIAL REPORT (SIR)
Use this form after all other forms applicable to this event (incident or near miss) or unsafe condition reported on the
Healthcare Event Reporting Form (HERF) have been reviewed. Highlighted fields are collected for local facility and PSO
use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. What is the date of this report?

___ ___ / ___ ___ / ___ ___ ___ ___
MM

YYYY

2. Where did the event occur, or, if an unsafe condition, where does it exist? (PLEASE REFER TO HERF QUESTION 6) CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

Inpatient general care area (e.g., medical/surgical unit)
Special care area (e.g., ICU, CCU, NICU)
Labor and delivery
Operating room or procedure area (e.g., cardiac catheter lab, endoscopy area), including PACU or recovery
area
Radiology/imaging department, including onsite mobile units
Pharmacy
Laboratory, including pathology department and blood bank
Emergency department
Other area within the facility
Outpatient care area
Outside area (i.e., grounds of this facility)
Unknown
Other: PLEASE SPECIFY ___________________________________________________________________

3. Who reported the event or unsafe condition? (PLEASE REFER TO HERF QUESTION 18) CHECK ONE:

a.
b.

c.
d.
e.

Healthcare professional
Healthcare worker, including liaison officer,
patient transport/retrieval personnel,
assistant/orderly, clerical/administrative
personnel, domestic/hotel service personnel,
interpreter/translator, technical/laboratory
personnel, pastoral care personnel, or
biomedical engineer
Emergency service personnel, including police
officer, fire fighter, or other emergency service
officer
Patient/relative/volunteer/caregiver/home
assistant
Anonymous or unknown

4. What is the type of healthcare professional? CHECK ONE:

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 5

a.
b.
c.
d.

Doctor, dentist (including student)
Nurse, nurse practitioner, physician assistant
(including student or trainee)
Pharmacist, pharmacy technician (including
student)
Allied health personnel, paramedic

Summary of Initial Report (SIR)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

5. Please describe any additional details about the event or unsafe condition discovered after completion of the HERF:

IF UNSAFE CONDITION

STOP

This form is complete.

IF NEAR MISS, ANSWER QUESTIONS 6 - 12

IF INCIDENT, ANSWER QUESTIONS 7 - 13

6. What prevented the near miss from reaching the patient? CHECK ONE:

a.
b.
c.
d.
e.
f.

Fail-safe designed into the process and/or a safeguard worked effectively
Practitioner or staff who made the error noticed and recovered from the error (avoiding any possibility of it
reaching the patient)
Spontaneous action by a practitioner or staff member (other than person making the error) prevented the event
from reaching the patient
Action by the patient or patient’s family member prevented the event from reaching the patient
Other
Unknown

7. Was the event associated with a handover/handoff? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 5

Summary of Initial Report (SIR)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

8. Are any contributing factors to the event known? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

9. What factor(s) contributed to the event? CHECK ALL THAT APPLY:

Environment
a.
Culture of safety, management
b.
Physical surroundings (e.g., lighting, noise)
Staff qualifications
c.
Competence (e.g., qualifications, experience)
d.
Training
Supervision/support
e.
Clinical supervision
f.
Managerial supervision
Policies and procedures, includes clinical protocols
g.
Presence of policies
h.
Clarity of policies
Equipment/device
i.
Function
j.
Design
k.
Availability
l.
Maintenance
Data
m.
Availability
n.
Accuracy
o.
Legibility
Communication
p.
Supervisor to staff
q.
Among staff or team members
r.
Staff to patient (or family)
Human factors
s.
Fatigue
t.
Stress
u.
Inattention
v.
Cognitive factors
w.
Health issues
Other
x.
Other: PLEASE SPECIFY ________________________________________________

10. Was health information technology (HIT) implicated in this event? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. Was the event a National Quality Forum (NQF) Serious Reportable Event? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

ANSWER QUESTION 13

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 3 of 5

Summary of Initial Report (SIR)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

12. What was the applicable Serious Reportable Event? CHECK ONE:

Surgical Events
Surgery performed on the wrong body part
a.
Surgery performed on the wrong patient
b.
c.
Wrong surgical procedure performed on a patient
Unintended retention of a foreign object in a patient after surgery or other procedure
d.
Intraoperative or immediately postoperative death in an ASA Class I patient
e.
Product or Device Events
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided
f.
by the healthcare facility
Patient death or serious disability associated with the use or function of a device in patient care in which the
g.
device is used or functions other than as intended
Patient death or serious disability associated with intravascular air embolism that occurs while being cared for
h.
in a healthcare facility
Patient Protection Events
Infant discharged to the wrong person
i.
j.
Patient death or serious disability associated with patient elopement (disappearance)
Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility
k.
Care Management Events
Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug,
l.
wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
Patient death or serious disability associated with a hemolytic reaction due to the administration of
m.
ABO/HLA-incompatible blood or blood products
Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared
n.
for in a healthcare facility
Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is
o.
being cared for in a healthcare facility
Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in
p.
neonates
Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
q.
Patient death or serious disability due to spinal manipulative therapy
r.
Artificial insemination with the wrong donor sperm or wrong egg
s.
Environmental Events
Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
t.
u.
Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong
gas or is contaminated by toxic substances
v.
Patient death or serious disability associated with a burn incurred from any source while being cared for in a
healthcare facility
Patient death or serious disability associated with a fall while being cared for in a healthcare facility
w.
Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a
x.
healthcare facility
Criminal Events
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or
y.
other licensed healthcare provider
Abduction of a patient of any age
z.
aa.
Sexual assault on a patient within or on the grounds of a healthcare facility
Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that
bb.
occurs within or on the grounds of a healthcare facility

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 4 of 5

Summary of Initial Report (SIR)



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

IF NEAR MISS

STOP

This form is complete.

13. How preventable was the incident? CHECK ONE:

a.
b.
c.
d.
e.
f.

Almost certainly could have been prevented
Likely could have been prevented
Likely could not have been prevented
Almost certainly could not have been prevented
Provider does not make this determination by policy
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 5 of 5

Summary of Initial Report (SIR)

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

BLOOD OR BLOOD PRODUCT
Use this form to report any patient safety event or unsafe condition involving the processing and/or administration of
blood or a blood product. This form is not intended for reporting blood or blood product collection and other processes
prior to receipt of the product by the blood bank. If the event involves a device, please also complete the Device or
Medical/Surgical Supply form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF).
Highlighted fields are collected for local facility and PSO use. This information will not be forwarded to the Network of
Patient Safety Databases (NPSD).
1. What type of blood product was involved in the event? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.

Whole blood
Red blood cells
Platelets
Plasma
Cryoprecipitate
Granulocytes
Lymphocytes
Albumin
Factors (e.g., VII, VIII, IX, AT III)
IV immunoglobulin
RhIg
Other: PLEASE SPECIFY ___________________________________________________________________

2. What was the International Society of Blood Transfusion (ISBT) 8 digit
product code for the product associated with this event?
ISBT PRODUCT CODE

IF UNSAFE CONDITION

STOP

This form is complete.

3. Which of the following best describes the event? CHECK ONE:

a.
b.
c.

Incorrect action (e.g., patient given blood of wrong ABO type)
Adverse reaction during or following administration
without any apparent incorrect action
Unknown

AHRQ Common Formats – Hospital Version 1.1 – March 2010 Release
Page 1 of 3

STOP

This form is complete.

Blood or Blood Product



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

4. What incorrect action was involved in administering the blood or blood product? CHECK ONE:

a.
b.
c.
d.
e.
f.

Incorrect patient
Incorrect ABO/Rh type
Incorrect product (e.g., giving heterologous blood
product when autologous blood product should
have been given)
Incorrect sequence of administration
of products
Incorrect use of expired or unacceptably stored
products

5. Was a two-person, three-way check
documented? CHECK ONE:

Incorrect volume (i.e., number of units or milliliters)

6. What was the volume? CHECK ONE:

a.
b.
c.

a.
b.
c.
g.
h.
i.

Incorrect IV fluid (i.e., administered product with
incorrect IV fluid)
Incorrect timing (e.g., delay in administration)
Incorrect rate

Too much/too many
Too little/too few
Unknown

7. Was the rate of administration: CHECK ONE:

a.
b.
c.
j.
k.

Yes
No
Unknown

Too fast
Too slow
Unknown

Unknown
Other: PLEASE SPECIFY ________________________________

8. During which process was the event discovered (regardless of the stage when it originated)? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.

Product test or request
Sample collection
Sample handling
Sample receipt
Sample testing
Product storage
Available for issue
Product selection

i.
j.
k.
l.
m.
n.
o.

Product manipulation
Request for pickup
Product issue
Product administration
Post-transfusion or administration
Unknown
Other: PLEASE SPECIFY
____________________________________

9. During which process did the event originate (regardless of the stage when it was discovered)? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.

Product check-in
Product test or request
Sample collection
Sample handling
Sample receipt
Sample testing
Product storage
Available for issue

AHRQ Common Formats – Hospital Version 1.1 – March 2010 Release
Page 2 of 3

i.
j.
k.
l.
m.
n.
o.
p.

Product selection
Product manipulation
Request for pickup
Product issue
Product administration
Post-transfusion or administration
Unknown
Other: PLEASE SPECIFY
____________________________________

Blood or Blood Product



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

AHRQ Common Formats – Hospital Version 1.1 – March 2010 Release
Page 3 of 3

Blood or Blood Product

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

DEVICE OR MEDICAL/SURGICAL SUPPLY
Use this form to report any patient safety event or unsafe condition involving a defect, failure, or incorrect use of a device.
A device includes an implant, medical equipment, or medical/surgical supply (including disposable product). If the event
involves a medication or other substance, please also complete the Medication or Other Substance form. Narrative detail
can be captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected for local facility and
PSO use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. What type of device was involved in the event? CHECK ONE:

a.
b.
c.

Implantable device (e.g., device
intended to be inserted into, and
remain permanently in, tissue)
Medical equipment (e.g., nonimplantable device)
Medical/surgical supply, including
disposable product

2. At the time of the event, was
the device placed within the
patient’s tissue? CHECK ONE:

a.
b.
c.

3. Did the event result in the
device being removed?
CHECK ONE:

Yes
No
Unknown

a.
b.
c.

Yes
No
Unknown

4. What is the name (brand or generic) of the device, product, or medical/surgical supply?
_____________________________________________________________________________________________________
5. What is the name of the manufacturer?
_____________________________________________________________________________________________________
6. Which of the following best describes the event or unsafe condition? CHECK ONE:

Device failure

7. Which of the following best describes the device’s involvement in the
event? CHECK FIRST APPLICABLE:

a.
b.
c.
d.
e.
b.
c.
d.

Operator error
Combination or interaction of
device failure and operator error
Unknown

Device defect or failure directly impacted the patient
(e.g., pacemaker)
Device defect or failure was precursor to an event that reached
the patient (e.g., infusion pump delivered an overdose)
Device defect or failure created a near miss (e.g., instrument
breaks immediately before use)
Device defect or failure created an unsafe condition (e.g.,
device found to be defective during routine inspection or
maintenance)
Unknown

8. What type of operator error? CHECK ONE:

a.
b.
c.
d.
e.

Jury-rigging, creating a workaround, force-fitting, defeating
fail-safe, etc.
Selection or use of inappropriate device, including use of latexcontaining product when patient was known to be allergic to
latex
Mis-setting, mis-programming, or otherwise misusing the
device
Unknown
Other: PLEASE SPECIFY ___________________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 2

Device or Medical/Surgical Supply



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

9. Did the event involve reuse of a device intended for single use (including use of a reprocessed single-use device)?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

10. Which of the following identifiers are known? CHECK ALL THAT APPLY:

11. What is the model number?

Model number

__________________________________________________________

12. What is the serial number?

Serial number

__________________________________________________________

Lot or batch number

13. What is the lot or batch number?
__________________________________________________________

Other unique product identifier

14. What is the type of other unique product identifier?
__________________________________________________________
15. What is the other unique product identifier?
__________________________________________________________

16. What is the expiration date?

Date of expiration

___ ___ / ___ ___ / ___ ___ ___ ___
MM

“Unique Device Identifier”

YYYY

17. What is the “Unique Device Identifier” (UDI)?
__________________________________________________________

No identifiers known

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 2

Device or Medical/Surgical Supply

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

FALL
Use this form to report details of a fall. For purposes of patient safety, a fall is a sudden, unintended, uncontrolled,
downward displacement of a patient's body to the ground or other object. This definition includes unassisted falls and
assisted falls (i.e., when a patient begins to fall and is assisted to the ground by another person). This definition excludes
near falls (loss of balance that does not result in a fall) and falls resulting from a purposeful action or violent blow.
Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected for
local facility and PSO use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. Was the fall unassisted or assisted? CHECK ONE:

a.
b.
c.

Unassisted
Assisted
Unknown

2. Was the fall observed? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

3. Who observed the fall? CHECK FIRST APPLICABLE:

a.
b.

Staff
Visitor, family, or another patient

4. Did the patient sustain a physical injury as a result of the fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

5. What type of injury was sustained? CHECK ONE; IF MORE THAN ONE, CHECK
MOST SEVERE:

a.
b.
c.
d.
e.

Dislocation
Fracture
Intracranial injury
Laceration requiring sutures
Other: PLEASE SPECIFY
_________________________________________________

6. Prior to the fall, what was the patient doing or trying to do? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Ambulating without assistance and without an assistive device or medical equipment
Ambulating with assistance and/or with an assistive device or medical equipment
Changing position (e.g., in bed, chair)
Dressing or undressing
Reaching for an item
Showering or bathing
Toileting-related activities
Transferring to or from bed, chair, etc.
Undergoing a diagnostic or therapeutic procedure
Unknown
Other: PLEASE SPECIFY ____________________________________________________________________

7. Prior to the fall, was a fall risk assessment performed? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

8. Was the patient determined to be at risk for a fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 2

Fall



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

9. What protocols/interventions were in place, or being used, to prevent falls for this patient? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.

Assistive devices (e.g., wheelchair, commode, cane, crutches, scooter, walker)
Bed or chair alarm
Bed in low position
Call light/personal items within reach
Fall alert
Change in medication (e.g., timing or dosing of current medication)
Non-slip footwear
Patient and family education
Patient situated close to the nurses’ station
Physical/occupational therapy
Siderails
Sitter
Toileting regimen
None
Unknown
Other: PLEASE SPECIFY ____________________________________________________________________

10. At time of the fall, was the patient on medication known to increase the risk for a fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. Was the medication considered to have contributed to the fall?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 2

Fall

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

HEALTHCARE-ASSOCIATED INFECTION
Use this form to report a healthcare-associated infection (HAI). An HAI is a localized or systemic condition resulting from
an adverse reaction to the presence of an infectious agent(s) or its toxin(s). It is acquired during the course of receiving
treatment for other conditions within a healthcare setting. For an inpatient care location, there must be no evidence that
the infection was present or incubating at the time of admission (except surgical site infection (SSI)). Narrative detail can be
captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected for local facility and PSO use.
This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
The Centers for Disease Control and Prevention’s National Health Safety Network (NHSN) gathers surveillance data on
four major types of healthcare-associated infections: surgical site infections (SSI), central line-associated bloodstream
infections (CLABSI), ventilator-associated pneumonias (VAP), and catheter-associated urinary tract infections (CAUTI).
Although the Common Formats capture information on additional types of HAIs, we limit capture of further detail on
HAIs to those tracked in the NHSN. Specific NHSN definitions are provided below.
Central line-associated Primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour
bloodstream infection period before the development of the BSI and that is not related to an infection at another
(CLABSI): site. http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Pneumonia (PNEU) that occurs in a patient who was intubated and ventilated at the time of,
Ventilator-associated or within 48 hours before, the onset of the PNEU.
pneumonia (VAP):
http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf
Catheter-associated
urinary tract infection
(CAUTI):

Urinary tract infection (UTI) that occurs in a patient who had an indwelling urinary catheter
in place within the 48-hour period before the onset of the UTI.
http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

Surgical site infection
(SSI):

For full details please refer to
http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

NOTE:

There is no minimum period of time that the device must be in place in order for the infection to be considered
device-associated.

1. Was the infection determined to be present or incubating on admission? CHECK ONE:

Yes – infection was determined to be present or incubating
on admission

b.
c.

No – infection developed during this admission
Unknown

ANSWER QUESTION 2

ANSWER QUESTION 3

2. Which of the following best describes the infection? CHECK ONE:

Surgical site infection (SSI) in a patient operated on at this facility
in the previous 30 days or, if an implant, in the previous year

Community acquired infection that was determined to be present
or incubating on admission with no treatment at any facility
Presumed HAI (other than SSI) that developed following a discharge
from this facility
Presumed HAI (other than SSI) that developed following treatment
at an outpatient site, operated by this facility
Presumed HAI that developed following treatment at another
inpatient or outpatient facility

c.
d.
e.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 3

ANSWER QUESTION 3

STOP

This form is complete.

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

3. Was the person who determined the infection to be a healthcare-associated infection (HAI) a healthcare
professional with specific training in infectious disease and/or infection control? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

4. What type of HAI is being reported? CHECK ONE:

Primary bloodstream
infection (BSI)

Pneumonia

Urinary tract
infection (UTI)

Surgical site infection
(SSI)

Other type of
infection (not
involving surgical site)
that developed during
admission

5. Was it central line-associated (CLABSI)? CHECK ONE:

Yes

ANSWER QUESTION 10

This form is complete.

STOP

6. Was it a ventilator-associated pneumonia (VAP - i.e., the patient had a device to
assist or control respiration continuously through a tracheostomy or by
endotracheal intubation)? CHECK ONE:

Yes

ANSWER QUESTION 11

This form is complete.

STOP

7. Was it catheter-associated (CAUTI)? CHECK ONE:

Yes

ANSWER QUESTION 12

This form is complete.

STOP

8. The SSI was classified as which of the following? CHECK FIRST APPLICABLE:

a.
b.
c.
d.
e.
f.

Organ/space
Deep incisional primary (DIP)
Deep incisional secondary (DIS)
Superficial incisional primary (SIP)
Superficial incisional secondary (SIS)
Unknown

9. Which other type of infection?

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

This form is complete.

PLEASE ALSO COMPLETE THE SURGERY
OR ANESTHESIA FORM

CHECK ONE:

Bone or joint infection
Central nervous system infection
Cardiovascular system infection
Eye, ear, nose, throat, or mouth
infection
Gastrointestinal system infection
Lower respiratory tract infection
(other than pneumonia)
Reproductive tract infection
Skin or soft tissue infection
Systemic infection
Other: PLEASE SPECIFY
_______________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 3

STOP

This form is complete.

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________
ONLY IF EVENT INVOLVED A CLABSI, ANSWER QUESTION 10

10. Which type of central line? CHECK ONE:

a.
b.
c.

Permanent (tunneled or implanted) central line
Temporary (non-tunneled) central line
Umbilical catheter

ANSWER QUESTION 14

ONLY IF EVENT INVOLVED A VAP, ANSWER QUESTION 11

11. The VAP was classified as which of the following? CHECK FIRST APPLICABLE:

a.
b.
c.

Pneumonia in an immunocompromised patient
determined by both clinical and laboratory criteria
Pneumonia with specific laboratory findings
Clinically defined pneumonia

ANSWER QUESTION 14

ONLY IF EVENT INVOLVED A CAUTI, ANSWER QUESTIONS 12 - 13

12. What was the urinary catheter status at the time of specimen collection that was the basis for diagnosis of CAUTI?
CHECK ONE:

a.
b.

In place at the time of specimen collection
Removed within 48 hours prior to specimen collection

13. The CAUTI was classified as which of the following? CHECK ONE:

a.
b.

Symptomatic UTI
Asymptomatic bacteremic UTI
ONLY IF EVENT INVOLVED A CLABSI, VAP, OR CAUTI, ANSWER QUESTION 14

14. At which inpatient location was the patient assigned when the specimen that met the infection criteria was
collected, or when the first clinical evidence of CLABSI, VAP, or CAUTI appeared? If the infection developed within
48 hours of transfer from one location to one or more other locations within this facility, select the patient’s first
such inpatient location within the 48 hour period where the central line, urinary catheter, or ventilator was used.
CHECK ONE:

a.
b.
c.
d.
e.

Specialty care area (i.e., hematology/oncology ward, bone marrow transplant unit, solid organ transplant unit,
inpatient dialysis unit, or long term acute care area)
Intensive care unit, including pediatric
Neonatal intensive care unit
Other location (e.g., surgical or medical ward)
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 3 of 3

Healthcare-associated Infection

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

MEDICATION OR OTHER SUBSTANCE
Use this form to report any patient safety event or unsafe condition involving a substance such as a medication, vaccine,
nutrient, dietary supplement, medical gas, or contrast media. Do not complete this form if the event involves
appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known
drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply form.
Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected for
local facility and PSO use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. What type of medication/substance was involved? CHECK ONE:

Medication

2. What type of medication?
CHECK ONE:

a.
b.
c.
d.

Prescription or over-thecounter
Compounded preparation
Investigational drug
Unknown

3. Please list all ingredients:
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Biological product

4. What type of biological product?
CHECK ONE:

a.
b.

Vaccine
Other biological product
(e.g., thrombolytic)

5. What was the lot number of the
vaccine?
LOT NUMBER

Nutritional product

Expressed human
breast milk
Medical gas (e.g.,
oxygen, nitrogen,
nitrous oxide)
Contrast media

e.
f.

6. What type of nutritional product?
CHECK ONE:

a.
b.
c.
d.
e.

g.
h.
i.

Radiopharmaceutical
Patient food (not
suspected in drugfood interactions)
Other substance:

STOP

Dietary supplement (other
than vitamins or minerals)
Vitamins or minerals
Enteral nutritional product,
including infant formula
Parenteral nutritional
product
Other: PLEASE SPECIFY
_____________________
This form is complete.

PLEASE SPECIFY

_________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 4

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

7. Which of the following best characterizes the event? CHECK ONE:

a.
b.
c.
d.

Incorrect action (process failure or error) (e.g., such as administering
overdose or incorrect medication, and other medication errors)
Unsafe condition
Adverse reaction in patient to the administered substance without
any apparent incorrect action
Unknown

ANSWER QUESTIONS 17 - 21

This form is complete.

STOP

8. What was the incorrect action? CHECK ALL THAT APPLY:

a.
b.
c.

Incorrect patient
Incorrect medication/substance
Incorrect dose(s)

9. Which best describes the incorrect dose(s)? CHECK ONE:

a.
b.
c.
d.

Incorrect route of administration

Incorrect timing

Overdose
Underdose
Missed or omitted dose

Given too early
Given too late

Incorrect rate

g.
h.

Too quickly
a.
Too slowly
b.
Incorrect duration of administration or course of therapy
Incorrect dosage form (e.g., sustained release instead of immediate release)

j.
k.

c.
Too high
Unknown
a.
Too low
b.
Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.
Expired or deteriorated
13. What was the expiration date? __ __ / __ __ / __ __ __ __
medication/substance
Medication/substance that is
known to be an allergen to
the patient

Medication/substance that is
known to be contraindicated for
the patient

YYYY

14. Was there a documented history of allergies or sensitivities to the
medication/substance administered? CHECK ONE:

a.
b.

Yes
No

Unknown

15. What was the contraindication (potential or actual interaction)?
CHECK ONE:

a.
b.
c.
n.
o.

Unknown

12. Which best describes the incorrect strength or concentration?
CHECK ONE:

Unknown

11. Which best describes the incorrect rate? CHECK ONE:

Incorrect strength or
concentration

Extra dose
Unknown

10. Which best describes the incorrect timing? CHECK ONE:

a.
b.

d.
e.

Drug-drug
Drug-food
Drug-disease

Other: PLEASE SPECIFY _____________________________
d.
Incorrect patient/family action (e.g., self-administration error)
Other: PLEASE SPECIFY ___________________________________________________________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 4

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

16. At what stage in the process did the event originate, regardless of the stage at which it was discovered?
CHECK ONE:

a.
b.
c.
d.
e.

Purchasing
Storing
Prescribing/ordering
Transcribing
Preparing

f.
g.
h.
i.
j.

Dispensing
Administering
Monitoring
Unknown
Other: PLEASE SPECIFY
____________________________________

QUESTIONS 17 - 23 DO NOT APPLY TO COMPOUNDED PREPARATION OR EXPRESSED HUMAN BREAST MILK
FOR AN INCIDENT, ANSWER QUESTIONS 17-23
FOR A NEAR MISS, ANSWER QUESTIONS 17-22
FOR AN UNSAFE CONDITION, ANSWER QUESTIONS 17-21

Please provide the following medication details for any medications or other substances directly involved in the event.
17. Generic

name or
investigational
drug name

18. Brand name 19. Manufacturer 20. Strength or
(if known)

(if known)

concentration
of product

21. Dosage

form of
product

22. Was this

medication/
substance
prescribed for
this patient

23. Was this

medication/
substance
given to this
patient?

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

IF THIS EVENT DID NOT INVOLVE AN INCORRECT ROUTE OF ADMINISTRATION

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 3 of 4

STOP

This form is complete.

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________
IF THE EVENT INVOLVED AN INCORRECT ROUTE OF ADMINISTRATION, ANSWER QUESTIONS 24 - 25

24. What was the intended route of administration?
CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.

25. What was the actual route of administration
(attempted or completed)? CHECK ONE:

Cutaneous, topical application, including
ointment, spray, patch
Subcutaneous
Ophthalmic
Oral, including sublingual or buccal
Otic
Nasal
Inhalation
Intravenous
Intramuscular
Intrathecal
Epidural
Gastric
Rectal
Vaginal
Unknown
Other: PLEASE SPECIFY
_____________________________________

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.

Thank you for completing these questions.
OMB No. 0935-0143
Exp. Date 8/31/2011
Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 4 of 4

Medication or Other Substance

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

PERINATAL
Use this form to report any patient safety event associated with the birthing process or intrauterine procedures that occur
during the perinatal period to the mother, fetus(es), or neonate(s). The perinatal period extends from the 20th week of
gestation through 4 weeks (28 days) postpartum. Narrative detail can be captured on the Healthcare Event Reporting
Form (HERF). Highlighted fields are collected for local facility and PSO use. This information will not be forwarded to the
Network of Patient Safety Databases (NPSD).
If a single event affected the mother, and/or fetus or neonate, use one perinatal event form. In the rare circumstance
when a single event affects more than one neonate, fill out this form for the most severely affected neonate and note injury
to other neonate(s) in the narrative.
1. Which of the following did the event involve? CHECK ONE:

a.
b.
c.
d.

Birthing process (labor and delivery)
Intrauterine procedure (prenatal)
Other
Unknown

STOP

This form is complete.

2. Who was affected by the event? CHECK ONE:

a.
b.
c.

Mother
Mother and fetus(es)
Mother and neonate

3. Was the mother a primipara? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

4. How many fetuses were in this pregnancy? ENTER NUMBER:
COUNT FETUSES WHETHER OR NOT BORN ALIVE. IF A FETAL REDUCTION WAS PERFORMED, COUNT THE NUMBER AFTER SUCH
REDUCTION.
NUMBER

5. Immediately prior to delivery, or at the time of the intrauterine procedure (prenatal), what was the best estimate of
completed weeks of gestation? CHECK ONE:

a.
b.
c.
d.
e.

20-< 36 weeks
36-< 38 weeks
38-< 42 weeks
42 weeks or more
Unknown
IF THIS EVENT INVOLVED THE BIRTHING PROCESS, ANSWER QUESTIONS 6 - 16

IF THIS EVENT INVOLVED AN INTRAUTERINE PROCEDURE, ANSWER QUESTIONS 14 - 16

6. What was the date of delivery?

___ ___ / ___ ___ / ___ ___ ___ ___
MM

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 3

YYYY

Perinatal



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

7. Was labor induced or augmented? CHECK ONE:

a.
b.
c.

8. Which one? CHECK ONE:

Yes
No
Unknown

a.
b.

Induced
Augmented

9. What was the final mode of delivery? CHECK ONE:

a.
b.
c.

Vaginal delivery
Cesarean section
Unknown

10. Regardless of the final mode of delivery, was instrumentation used to assist vaginal (or attempted vaginal) delivery?
CHECK ONE:

a.
b.
c.

11. What instrumentation was used? CHECK ONE:

Yes
No
Unknown

a.
b.
c.

Vacuum
Forceps
Vacuum followed by forceps

12. Number of live births:
ENTER NUMBER

13. What was the neonate’s birthweight?
ENTER IN GRAMS

14. Which adverse outcome(s) did the mother sustain? CHECK ALL THAT APPLY:

a.
b.
c.

Hemorrhage requiring transfusion
Eclampsia
Magnesium toxicity

Infection

15. Which of the following maternal infections? CHECK ONE:

a.
b.
c.
e.
f.
g.
h.

Injury to body part or organ
Death
Neonate/fetal injury only
Other: PLEASE SPECIFY
_______________________

Chorioamnionitis
Endometritis
Other: PLEASE SPECIFY _____________________________

16. Which body part(s) or organ(s)? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.

Uterine rupture
Third- or fourth-degree perineal laceration
Ureter
Bladder
Bowel
Other: PLEASE SPECIFY _____________________________

ONLY IF EVENT AFFECTED A FETUS, ANSWER QUESTION 17

17. What adverse outcome did the fetus sustain? CHECK FIRST APPLICABLE:

a.
b.

Unexpected death
Injury

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 3

STOP

This form is complete.
Perinatal



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________
ONLY IF EVENT AFFECTED A NEONATE, ANSWER QUESTIONS 18 - 20

18. What was the 5-minute Apgar score?
APGAR SCORE

19. Which adverse outcome(s) did the neonate sustain? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.

Birth trauma as listed under ICD-9-CM 767
Five-minute Apgar < 7 and birthweight > 2500 grams
Anoxic or hypoxic encephalopathy
Seizure(s)
Infection (e.g., group B strep)
Unexpected death
Other: PLEASE SPECIFY _________________________

20. Which birth trauma? CHECK ONE:

a.
b.
c.

Subdural or cerebral hemorrhage
Injury to brachial plexus
Other: PLEASE SPECIFY
_______________________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 3 of 3

Perinatal

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

PRESSURE ULCER
Use this form to report a pressure ulcer or suspected Deep Tissue Injury that was 1) not present on admission (i.e., newlydeveloped), or 2) worsened during the patient’s stay. Report only an event that occurred prior to patient discharge.
Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected for
local facility and PSO use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
Stage 1:

Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.

Stage 2:

Partial-thickness tissue loss of dermis presenting as a shallow open ulcer with a red/pink wound bed,
without slough.

Stage 3:

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not
exposed.

Stage 4:

Full-thickness tissue loss with exposed bone, tendon, or muscle.

Unstageable:

Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the
wound bed.

Suspected Deep
Tissue Injury:

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear.

1. What was the most advanced stage of the pressure ulcer or suspected Deep Tissue Injury being reported? CHECK ONE:

a.
b.

Stage 1
Stage 2

Suspected Deep Tissue Injury

d.
e.
f.
g.
h.

Stage 3
Stage 4
Unstageable
Mucosal ulcer only (no skin involvement)
Unknown

STOP

This form is complete.
GO TO QUESTION 2
GO TO QUESTION 3

STOP

This form is complete.

2. What was the status of the suspected Deep Tissue Injury on admission? CHECK ONE:

Present as suspected Deep Tissue Injury

b.
c.
d.

Present as a Stage 1 pressure ulcer
Not present
Unknown

STOP

This form is complete.
GO TO QUESTION 4

3. What was the status of the Stage 3, 4, or unstageable pressure ulcer on admission? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.

Not present
Stage 1
Stage 2
Suspected Deep Tissue Injury
Stage 3
Stage 4
Unstageable

Unknown

GO TO QUESTION 4

STOP

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 3

This form is complete.

GO TO QUESTION 4
Pressure Ulcer



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

4. On admission to this facility, was a skin inspection documented? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

5. When was the first pressure ulcer risk assessment performed? CHECK ONE:

a.
b.
c.
d.
e.

On admission (within 24 hours)
Not on admission, but done prior to the discovery
of a newly-developed, or advancement of an
existing, pressure ulcer
Not on admission, but done after discovery of a
newly-developed, or advancement of an existing,
pressure ulcer
No risk assessment performed
Unknown

6. What type of risk assessment was performed?
CHECK FIRST APPLICABLE:

a.
b.
c.

Formal assessment (e.g., Braden, Braden Q
(pediatric version), Norton, Waterlow)
Clinical assessment
Unknown

7. As a result of the assessment, was the patient
documented to be at increased risk for pressure
ulcer? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

8. Was any preventive intervention implemented? CHECK ONE:

a.
b.
c.

9. What intervention(s) was used?
CHECK ALL THAT APPLY:

Yes
No
Unknown

a.
b.
c.
d.

Pressure redistribution device
Repositioning
Nutritional support
Other: PLEASE SPECIFY
__________________________________

10. Was the use of a device or appliance involved in the development or advancement of the pressure ulcer? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. What was the type of device or
appliance? CHECK ONE:

a.
b.
c.
d.
e.
f.

Anti-embolic device
Intraoperative positioning device
Orthopedic appliance (e.g., cast,
splint, orthotic)
Oxygen delivery device (e.g.,
nasal prongs, oxygen mask)
Tube
Other: PLEASE SPECIFY
______________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 3

12. What was the type of tube?
CHECK ONE:

a.
b.
c.
d.
e.
f.

Endotracheal
Gastrostomy
Nasogastric
Tracheostomy
Indwelling urinary catheter
Other: PLEASE SPECIFY
______________________
Pressure Ulcer



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

13. During the patient’s stay at this facility, did the patient develop a secondary morbidity (e.g., osteomyelitis or
sepsis)? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

14. Was the secondary morbidity attributed to the presence of the pressure
ulcer or suspected Deep Tissue Injury? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
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Pressure Ulcer

Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

Patient Safety Event Report:

SURGERY OR ANESTHESIA
Use this form to report an event involving a surgical or other invasive procedure (e.g., colonoscopy), or the administration
of anesthesia. Do not complete this form if the event involved the removal of organs from brain-dead patients (ASA Class
6) or handling an organ after procurement. If the event involved an anesthetic device, please also complete the Device or
Medical/Surgical Supply form. If the event involved an anesthetic, medical gas, medication, or other substance, please also
complete the Medication or Other Substance form. If the event involved a healthcare-associated infection, please also
complete the Healthcare-associated Infection form. Narrative detail can be captured on the Healthcare Event Reporting
Form (HERF). Highlighted fields are collected for local facility and PSO use. This information will not be forwarded to
the Network of Patient Safety Databases (NPSD).
1. Describe briefly the procedure associated with this event:

2. Enter ICD-9-CM procedure code associated with this event:
ICD-9-CM CODE

3. What was the patient’s documented American Society of Anesthesiologists (ASA) Physical Classification System
class? CHECK ONE:

a.
b.
c.

d.
e.
f.

Class 1
Class 2
Class 3

Class 4
Class 5
ASA classification was not documented

4. Was the procedure performed as an emergency? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

5. When was the event discovered? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Before anesthesia started (or no anesthesia used)
After anesthesia started, but before incision or
start of procedure
After procedure started (incision) but before
procedure ended (closure)
At closure, if surgical operation
After procedure ended, but before patient left
operating room or other procedure area
During post-anesthesia care/recovery period
After post-anesthesia recovery, but before
discharge
After patient was discharged
During anesthesia when no surgical operation or
invasive procedure was performed
Unknown

6. What was the total length of the procedure (i.e.,
induction of anesthesia to the end of anesthesia)?
CHECK ONE:

a.
b.
c.
d.
e.

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 1 of 5

Less than 1 hour
Greater than or equal to 1 hour, but less than
3 hours
Greater than or equal to 3 hours, but less than
5 hours
Greater than or equal to 5 hours
Unknown

Surgery or Anesthesia



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

7. What type of anesthesia or sedation was used?

a.
b.
c.
d.

CHECK FIRST APPLICABLE:

General anesthesia
Regional anesthesia (e.g., epidural, spinal, or
peripheral nerve blocks)
Local or topical anesthesia
Sedation only

8. What was the level of sedation? CHECK ONE:

a.
b.
c.
d.
e.

Deep sedation or analgesia
Moderate sedation or analgesia (conscious
sedation)
Minimal sedation (anxiolysis)
No sedation (if regional, local, or topical
anesthesia)
Unknown
ANSWER QUESTION 11

None

9. Who administered (or, if the event occurred prior to administration of anesthesia, person who was scheduled to
administer) the anesthesia? CHECK ONE:

a.
b.
c.
d.

Anesthesiologist
Certified Registered Nurse Anesthetist
Other healthcare professional
Unknown

10. Was there supervision by an anesthesiologist?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. What was the medical or surgical specialty of the provider who performed the procedure? CHECK ONE:
SELECT THE SPECIALTY OF THE PROVIDER OR TEAM THAT PERFORMED THE PROCEDURE. IF THE PROCEDURE WAS NOT STARTED, SELECT THE
SPECIALTY OF THE PROVIDER WHO WAS SCHEDULED TO PERFORM THE PROCEDURE.

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

Anesthesiology
Cardiology
Colorectal surgery
Dentistry, including oral surgery
Dermatology
Emergency medicine
Family medicine
Gastroenterology
General surgery
Internal medicine
Neurological surgery
Obstetrics/Gynecology
Ophthalmology

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 2 of 5

n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.

Orthopedic surgery
Otolaryngology
Pediatrics
Pediatric surgery
Plastic surgery
Podiatry
Pulmonology
Radiology, including vascular and interventional
Thoracic surgery
Urology
Vascular surgery
Other: PLEASE SPECIFY
_____________________________________

Surgery or Anesthesia



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

12. What best describes the event? CHECK ONE:

Surgical event

ANSWER QUESTION 15

Anesthesia event

ANSWER QUESTION 24

Major complication that could be associated
with either surgery or anesthesia

ANSWER QUESTION 13

13. Which of the following major complications occurred? CHECK ONE:

a.
b.
c.
d.
e.

Cardiac or circulatory event
Central nervous system event
Renal failure, impairment, or insufficiency
Respiratory failure, requiring unplanned
respiratory support, within 24 hours after the
procedure
Other: PLEASE SPECIFY
___________________________________

14. Which of the following best describes the respiratory
support provided? CHECK ONE:

a.
b.

Prolonged ventilator support
Re-institution of ventilator following
discontinuation
Other: PLEASE SPECIFY
_______________________________________

IF MAJOR COMPLICATION

STOP

This form is complete.

15. Was the surgical event an unintentionally retained object? CHECK ONE:

a.
b.

Yes
No

ANSWER QUESTION 21

16. What type of object was retained? CHECK ONE:

a.
b.
c.
d.
e.
f.

Sponge
Needle
Towel
Whole instrument (e.g., clamp)
Instrument fragment
Other: PLEASE SPECIFY _______________________________________________________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
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Surgery or Anesthesia



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

17. Was a count performed for the type of object that was retained? CHECK ONE:

b.
c.
d.

18. After counting, what was the reported count status? CHECK ONE:

Yes

No, object “countable”
No, object not “countable”
(e.g., broken piece retained)
Unknown

Incorrect (unreconciled)
count

Correct (reconciled) count

STOP

ANSWER QUESTION 19

STOP

This form is complete.

19. Was an x-ray obtained before the end of the procedure to detect the retained object? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

20. Was the retained object radiopaque (i.e., detectable by x-ray)? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

STOP

IF RETAINED OBJECT

This form is complete.

21. Which of the following best characterizes the surgical event? CHECK ONE:

a.
b.

Surgical site infection
Bleeding requiring return to the
operating room

Burn and/or operating room fire

ALSO COMPLETE THE HEALTHCARE-ASSOCIATED INFECTION FORM

22. Which of the following occurred?

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Incorrect surgical or invasive
procedure
Iatrogenic pneumothorax
Unintended laceration or puncture
Dehiscence, flap or wound failure or
disruption, or graft failure
Unintended blockage, obstruction, or
ligation
Unplanned removal of organ
Air embolus
Other: PLEASE SPECIFY
___________________________

CHECK ONE:

Burn
Operating room fire
Both

23. What was incorrect about the surgical or invasive procedure?
CHECK FIRST APPLICABLE:

a.
b.
c.
d.
e.
f.
g.

Incorrect patient
Incorrect side
Incorrect site
Incorrect procedure
Incorrect implant by mistake
Incorrect implant because correct implant was not
available
Other: PLEASE SPECIFY __________________________

IF SURGICAL EVENT

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 4 of 5

STOP

This form is complete.

Surgery or Anesthesia



Event ID: __________________________
Initial Report Date (HERF Q17): __________________________

24. If the event involved anesthesia, which of the following best characterizes the event? CHECK ONE:

a.
b.
c.
d.
e.
f.

Dental injury
Ocular injury
Peripheral nerve injury
Awareness (during anesthesia)
Malignant hyperthermia
Problem with anesthetic, medical
gas, medication, or other substance

Problem with device used in the
delivery of anesthesia

Difficulty managing airway

Other: PLEASE SPECIFY
____________________________

ALSO COMPLETE THE MEDICATION OR OTHER SUBSTANCE FORM
ALSO COMPLETE THE DEVICE OR MEDICAL/SURGICAL SUPPLY FORM

25. Which of the following best characterizes the airway
management problem? CHECK ONE:

a.
b.
c.
d.
e.

Difficulty during tracheal intubation
Difficulty maintaining airway during procedure
Esophageal intubation
Re-intubation, following extubation, in the operating or
recovery room
Other: PLEASE SPECIFY ___________________________

AHRQ Common Formats - Hospital Version 1.1 - March 2010 Release
Page 5 of 5

Surgery or Anesthesia

AHRQ Common Formats for
Skilled Nursing Facilities
Forms

Event ID: _______________
Initial Report Date (HERF Q12): _______________

Patient Safety Event Report – Skilled Nursing Facility:

HEALTHCARE EVENT REPORTING FORM (HERF)
Use this form to report either a patient safety event or unsafe condition. The term event includes both an incident that
reached the patient/resident and a near miss that did not. Highlighted fields are collected for local facility and Patient
Safety Organization (PSO) use. This information will not be forwarded to the Network of Patient Safety Databases
(NPSD).
1. What is being reported? check one:

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

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

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

2. Event Discovery Date:

___ ___

/ ___ ___ / ___ ___ ___ ___

3. Event Discovery Time:

Unknown

YYYY

___ ___ ___ ___
H

HOURS

H
M
M
(MILITARY TIME)

4. Briefly describe the event that occurred or unsafe condition:

5. Briefly describe the location where the event occurred or where the unsafe condition exists:

6. Which of the following categories are associated with the event or unsafe condition? CHECK ALL THAT APPLY:
FOR EACH CATEGORY SELECTED BELOW, EXCEPT ABUSE OR NEGLECT, ACCIDENT, ELOPEMENT OR “OTHER”, PLEASE COMPLETE THE
CORRESPONDING CATEGORY-SPECIFIC FORM. ALL CATEGORIES INCLUDE REPORTING OF INCIDENTS. ANY CATEGORY WITH + ALSO
INCLUDES REPORTING OF NEAR MISSES. ANY CATEGORY WITH * ALSO INCLUDES REPORTING OF UNSAFE CONDITIONS.

a.
b.
c.
d.

Abuse or Neglect
Accident (e.g., scalding, choking, and/or
restraint related)
Device or Supply, Including Health
Information Technology (HIT)*+
Elopement

e.
f.
g.
h.
i.

Fall
Healthcare-associated Infection
Medication or Other Substance*+
Pressure Ulcer
Other*+: PLEASE SPECIFY
________________________________________

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 2

Healthcare Event Reporting Form (HERF) 

Event ID: _______________
Initial Report Date (HERF Q12): _______________

PATIENT INFORMATION (COMPLETE ONLY IF INCIDENT):
Please complete the patient/resident identifiers below.
7. Patient’s/Resident’s Name:
FIRST

8. Patient’s/Resident’s
Date of Birth:

MIDDLE

___ ___ / ___ ___ / ___ ___ ___ ___
MM

10. Patient’s/Resident’s Gender:

LAST

9. Medical Record #:

YYYY

Male

ENTER NUMBER

Female

Unknown

11. How many patients/residents did the incident reach?
ENTER NUMBER

REPORT AND EVENT REPORTER INFORMATION
12. Report Date: ___ ___ / ___ ___ / ___ ___ ___ ___ 13.
MM

Anonymous Reporter

YYYY

14. Reporter’s Name:
FIRST

15. Telephone Number:

MIDDLE

LAST

16. Email Address:

17. Reporter’s Job or Position:

Thank you for completing these questions.
OMB No. 0935-0143

Exp. Date 8/31/2011

Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ
Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD
20850.

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 2

Healthcare Event Reporting Form (HERF)

Event ID: _______________
Initial Report Date (HERF Q12): _______________

Patient Safety Event Report – Skilled Nursing Facility:

PATIENT INFORMATION FORM (PIF)
Use this form only if you are reporting an incident. Highlighted fields are collected for local facility and Patient Safety
Organization (PSO) use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. At the time of the event what was the patient’s/resident’s age? CHECK ONE:

a.
b.
c.
d.

Infant or neonate (<1 year of age)
Child (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)

e.
f.
g.
h.

Mature adult (65-74 years)
Older adult (75-84 years)
Aged adult (85+ years)
Unknown

2. Is the patient’s/resident’s ethnicity Hispanic or Latino? CHECK ONE:

a.
b.
c.

Hispanic or Latino
Not Hispanic or Latino
Unknown

3. What is the patient’s/resident’s race? CHECK ONE:

a.
b.
c.
d.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander

e.
f.
g.

White
More than one race
Unknown

4. Was any intervention attempted in order to “rescue” the patient/resident (i.e., to prevent, to minimize, or to reverse
harm)? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

5. Which of the following interventions (rescue) were performed?
CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.
h.

Transfer, including transfer to a higher level care area within facility,
transfer to another facility, or admission to hospital
Monitoring, including observation, physiological examination, laboratory
testing, phlebotomy, and/or imaging studies
Medication therapy, including administration of antidote, change in
pre-incident dose or route
Surgical/procedural intervention
Respiratory support (e.g., ventilation, tracheotomy)
Counseling or psychotherapy
Unknown
Other intervention: PLEASE SPECIFY ____________________________

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 2

Patient Information Form (PIF) 

Event ID: _______________
Initial Report Date (HERF Q12): _______________

6. After discovery of the incident, and any subsequent intervention, what was the extent of harm to the
patient/resident (i.e., extent to which the patient’s/resident’s functional ability is expected to be impaired
subsequent to the incident and any attempts to minimize adverse consequences)? CHECK FIRST APPLICABLE:

AHRQ Harm Scale
a.
Death: Dead at time of assessment.
b.
Severe permanent harm: Severe lifelong bodily or psychological injury or disfigurement that interferes
significantly with functional ability or quality of life. Prognosis at time of assessment.
c.
Permanent harm: Lifelong bodily or psychological injury or increased susceptibility to disease. Prognosis at
time of assessment.
d.
Temporary harm: Bodily or psychological injury, but likely not permanent. Prognosis at time of assessment.
e.
Additional treatment: Injury limited to additional intervention during admission or encounter and/or
increased length of stay, but no other injury. Treatment since discovery, and/or expected treatment in future
as a direct result of event.
f.
Emotional distress or inconvenience: Mild and transient anxiety or pain or physical discomfort, but without
the need for additional treatment other than monitoring (such as by observation; physical examination;
laboratory testing, including phlebotomy; and/or imaging studies). Distress/inconvenience since discovery,
and/or expected in future as a direct result of event.
g.
No harm: Event reached patient/resident but no harm was evident.
h.
Unknown
7. Approximately when after discovery of the incident was harm assessed? CHECK ONE:

a.
b.
c.
d.

Within 24 hours
After 24 hours but before 3 days
Three days or later
Unknown

8. After the discovery of the incident, was the patient/resident, patient’s/resident’s family, or guardian notified?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 2

Patient Information Form (PIF)

Event ID: _______________
Initial Report Date (HERF Q12): _______________

Patient Safety Event Report – Skilled Nursing Facility:

SUMMARY OF INITIAL REPORT (SIR)
Use this form after all other forms applicable to this event (incident or near miss) or unsafe condition reported on the
Healthcare Event Reporting Form (HERF) have been reviewed. Highlighted fields are collected for local facility and
Patient Safety Organization (PSO) use. This information will not be forwarded to the Network of Patient Safety Databases
(NPSD).
1. What is the date of this report?

___ ___ / ___ ___ / ___ ___ ___ ___
MM

YYYY

2. Where did the event occur, or, if an unsafe condition, where does it exist? (PLEASE REFER TO HERF QUESTION 5) CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Patient/resident room
Toileting, bathing, showering room
Indoor activity area (e.g., TV room, gym)
Dining room
Pharmacy
Nursing station
Treatment or procedure room (e.g., physical therapy)
Other area within the facility
Outside area (i.e., grounds of this facility)
Unknown
Other: PLEASE SPECIFY ___________________________________________________________________

3. Who reported the event or unsafe condition? (PLEASE REFER TO HERF QUESTION 17) CHECK ONE:

a.
b.

c.
d.
e.
f.

Healthcare professional
Healthcare worker, including liaison officer,
patient transport/retrieval personnel,
assistant/orderly, clerical/administrative
personnel, domestic/hotel service personnel,
interpreter/translator, technical/laboratory
personnel, pastoral care personnel, or
biomedical engineer
Emergency service personnel, including police
officer, fire fighter, or other emergency service
officer
Patient/resident, relative, volunteer, caregiver,
or homecare assistant
Unknown
Other: PLEASE SPECIFY
_____________________________________

4. What is the type of healthcare professional? CHECK ONE:

a.
b.
c.
d.

Doctor or dentist (including student)
Nurse, nurse practitioner, or physician assistant
(including student or trainee)
Pharmacist or pharmacy technician (including
student)
Allied health personnel, paramedic

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 3

Summary of Initial Report (SIR)

Event ID: _______________
Initial Report Date (HERF Q123): _______________

5. Please describe any additional details about the event or unsafe condition discovered after completion of the HERF:

IF UNSAFE CONDITION

STOP

This form is complete.

IF NEAR MISS, ANSWER QUESTIONS 6 - 9

IF INCIDENT, ANSWER QUESTIONS 7 - 10

6. What prevented the near miss from reaching the patient/resident? CHECK ONE:

a.
b.
c.
d.
e.
f.

Fail-safe designed into the process and/or a safeguard worked effectively
Practitioner or staff member who made the error noticed and recovered from the error (avoiding any
possibility of it reaching the patient/resident)
Spontaneous action by a practitioner or staff member (other than person making the error) prevented the event
from reaching the patient/resident
Action by the patient/resident or family member prevented the event from reaching the patient/resident
Other
Unknown

7. Was the event associated with a handover/handoff? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 3

Summary of Initial Report (SIR) 

Event ID: _______________
Initial Report Date (HERF Q123): _______________

8. Are any contributing factors to the event known? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

9. What factor(s) contributed to the event? CHECK ALL THAT APPLY:

Environment
a.
Culture of safety, management
b.
Physical surroundings (e.g., lighting, noise)
Staff qualifications
c.
Competence (e.g., qualifications, experience)
d.
Training
Supervision/support
e.
Clinical supervision
f.
Managerial supervision
Policies and procedures, includes clinical protocols
g.
Presence of policies
h.
Clarity of policies
Data
i.
Availability
j.
Accuracy
k.
Legibility
Communication
l.
Supervisor to staff
m.
Among staff or team members
n.
Staff to patient/resident (or family)
Human factors
o.
Fatigue
p.
Stress
q.
Inattention
r.
Cognitive factors
s.
Health issues
Other
t.
Other: PLEASE SPECIFY ________________________________________________

IF NEAR MISS

STOP

This form is complete.

10. How preventable was the incident? CHECK ONE:

a.
b.
c.
d.
e.
f.

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 3 of 3

Summary of Initial Report (SIR)

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

Patient Safety Event Report – Skilled Nursing Facility:

DEVICE OR SUPPLY, INCLUDING
HEALTH INFORMATION TECHNOLOGY (HIT)

Use this form to report any patient safety event or unsafe condition involving a defect, failure, or incorrect use of a device,
including an HIT device. A device includes an implant, medical equipment, or medical/surgical supply (including
disposable product). An HIT device includes hardware or software that is used to electronically create, maintain, analyze,
store, receive, or otherwise aid in the diagnosis, cure, mitigation, treatment, or prevention of disease, and that is not an
integral part of (1) an implantable device or (2) an item of medical equipment.
Do not complete this form to report a manufacturing quality control problem, device defect or failure, or potential unsafe
condition discovered prior to market approval or, in the case of an HIT device, clinical deployment. If the event also
involves a medication or other substance, please complete the Medication or Other Substance form in addition to this
form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Highlighted fields are collected
for local facility and Patient Safety Organization (PSO) use. This information will not be forwarded to the Network of
Patient Safety Databases (NPSD).
1. Which of the following best describes the event or unsafe condition? CHECK ONE:

Device failure

2. Which of the following best describes the effect of the device failure?
CHECK FIRST APPLICABLE:

a.
b.
c.

d.
e.
b.
c.
d.

Use error
Combination or interaction of
device failure and use error
Unknown

Device defect or failure directly impacted the patient/resident
(e.g., pacemaker)
Device defect or failure or HIT device problem was precursor
to an event that reached the patient/resident (e.g., infusion
pump delivered an overdose of a drug)
Device defect or failure or HIT device problem resulted in a
near miss (e.g., instrument broke immediately before use,
realization prior to procedure that HIT system had indicated
wrong patient/resident)
Device defect or failure or HIT device problem created an
unsafe condition (e.g., device found to be defective during
routine inspection or maintenance)
Unknown

3. What type of use error? CHECK ONE:

a.
b.
c.
d.
e.
f.

Creating a workaround, force-fitting, defeating fail-safe
Inappropriate substitution or use of device, including an HIT
device (e.g., use of latex-containing product when
patient/resident was known to be allergic to latex)
Mis-setting, mis-programming, or otherwise misusing a device,
including an HIT device
Error in entering or interpreting data (e.g., wrong selection
from menu, transposition of numbers)
Unknown
Other: PLEASE SPECIFY _______________________________

4. Was a device intended for single use reused in the incident (including use of a reprocessed single-use device)?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facilities Beta Version - February 2011 Release
Page 1 of 4

Device or Supply, including Health

Information Technology (HIT)

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

5. What type of device was involved in the event? CHECK ONE:

a.
b.
c.
d.

Implantable device (i.e., device intended to be
inserted into, and remain permanently in, tissue)
Medical equipment (e.g., walker, hearing aid)
Medical/surgical supply, including disposable
product (e.g., incontinence supply)
HIT device

6. Did the event result in the device being removed?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

7. What is the name (brand or generic) of the device, product, software, or medical/surgical supply?
_____________________________________________________________________________________________________
8. What is the name of the manufacturer?
_____________________________________________________________________________________________________
9. Which of the following identifiers are known? CHECK ALL THAT APPLY:

Model number

10. What is the model number?
__________________________________________________________

Software/firmware version

11. What is the software/firmware version?
__________________________________________________________

Serial number

12. What is the serial number?
__________________________________________________________

Lot or batch number

13. What is the lot or batch number?
__________________________________________________________

Other unique product identifier

Date of expiration

16. What is the expiration date?
___ ___ / ___ ___ / ___ ___ ___ ___
MM

Unique Device Identifier

No identifiers known

YYYY

17. What is the Unique Device Identifier (UDI)?
__________________________________________________________

AHRQ Common Formats - Skilled Nursing Facilities Beta Version - February 2011 Release
Page 2 of 4

Device or Supply, including Health

Information Technology (HIT)

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

18. Did the event or unsafe condition involve a medication or other substance? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

ALSO COMPLETE THE MEDICATION OR OTHER SUBSTANCE FORM

IF THE EVENT DID NOT INVOLVE AN HIT DEVICE

STOP

This form is complete.

IF THE EVENT INVOLVED AN HIT DEVICE, ANSWER QUESTIONS 19 - 25

19. Which of the following best characterizes the HIT device related to the event or unsafe condition? CHECK ONE:

Administrative/billing or practice
management system

Automated dispensing system

Electronic health record (EHR) or
component of EHR

Human interface device (e.g., keyboard,
mouse, touchscreen, speech recognition
system, monitor/display, printer)

Laboratory information system (LIS),
including microbiology and pathology
systems

Radiology/diagnostic imaging
system, including picture archiving
and communications system (PACS)
Other: PLEASE SPECIFY
_________________________

20. Which component of the administrative/billing system?
CHECK ONE:

a.
b.
c.
d.
e.

Master patient index
Registration/appointment scheduling system
Coding/billing system
Unknown
Other: PLEASE SPECIFY
________________________________________

21. Which type or component of the EHR?
CHECK ONE:

a.
b.
c.
d.
e.
f.

Computerized provider order entry (CPOE) system
Pharmacy system
Clinical documentation system (e.g., progress notes)
Clinical decision support (CDS) system
Unknown
Other: PLEASE SPECIFY
________________________________________

AHRQ Common Formats - Skilled Nursing Facilities Beta Version - February 2011 Release
Page 3 of 4

Device or Supply, including Health

Information Technology (HIT)

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

22. Which of the following describes the circumstances involving the HIT device in the event or unsafe condition?
CHECK ALL THAT APPLY:

Incompatibility between devices

b.
c.
d.
e.

Equipment/device function
Equipment/device maintenance
Hardware failure
Network failure

23. Which problem(s) resulted from the equipment/device
function problem? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.

Ergonomics, including human/device
interface issue

24. Which ergonomics or human/device interface issue(s)?
CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
g.

Output from device during use

h.
i.
j.

Security, virus, or other malware issue
Unexpected software design issue
Other: PLEASE SPECIFY
____________________________

Error in charting, communication, or display of orders,
vital signs, or results
Loss of clinical data
Medication error - software related
System returns or stores wrong data for correctly
selected patient/resident
Other: PLEASE SPECIFY
___________________________________________

Alert fatigue/alarm fatigue
Data entry (e.g., selection of wrong patient/resident or
wrong provider using HIT device)
Hardware location (e.g., awkward placement for use)
Information display
Other: PLEASE SPECIFY
___________________________________________

25. Which output problem(s)? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.

Discrepancy between system data and printed, stored,
or exported data
Image measurement/corruption issue
Image orientation incorrect
Incorrect or inadequate test results
Incorrect software programming calculations
Other: PLEASE SPECIFY
___________________________________________

AHRQ Common Formats - Skilled Nursing Facilities Beta Version - February 2011 Release
Page 4 of 4

Device or Supply, including Health
Information Technology (HIT)

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

Patient Safety Event Report – Skilled Nursing Facility:

FALL
Use this form to report details of a fall. For purposes of patient/resident safety, a fall is a sudden, unintended,
uncontrolled, downward displacement of a patient's/resident’s body to the ground or other object (e.g., sink, table,
surrounding furniture). This definition includes unassisted falls and assisted falls (i.e., when a patient/resident begins to fall
and is assisted to the ground by another person). This definition excludes near falls (loss of balance that does not result in a
fall) and falls resulting from a purposeful action or violent blow. Narrative detail can be captured on the Healthcare Event
Reporting Form (HERF). Highlighted fields are collected for local facility and Patient Safety Organization (PSO) use. This
information will not be forwarded to the Network of Patient Safety Databases (NPSD).
1. Was the fall unassisted or assisted? CHECK ONE:

a.
b.
c.

Unassisted
Assisted
Unknown

2. Was the fall observed? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

3. Who observed the fall? CHECK FIRST APPLICABLE:

a.
b.

Staff
Visitor, family, or another patient/resident

4. Did the patient/resident sustain a physical injury as a result of the fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

5. What type of injury was sustained? CHECK ONE; IF MORE THAN ONE, CHECK
MOST SEVERE:

a.
b.
c.
d.
e.
f.

Dislocation
Fracture
Intracranial injury
Laceration requiring sutures
Skin tear/avulsion or significant bruising
Other: PLEASE SPECIFY
_________________________________________________

6. Prior to the fall, what was the patient/resident doing or trying to do? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Ambulating without assistance and without an assistive device or medical equipment
Ambulating with assistance and/or with an assistive device or medical equipment
Changing position (e.g., in bed, chair)
Dressing or undressing
Engaging in recreational activities (e.g., games, physical conditioning)
Reaching for an item
Showering or bathing
Toileting
Transferring to or from bed, chair, etc.
Unknown
Other: PLEASE SPECIFY ____________________________________________________________________

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 3

Fall



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

7. Prior to the fall, was a fall risk assessment performed? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

8. Was the patient/resident determined to be at increased risk for a
fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

9. Prior to the fall, were any of the following risk factors present? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.

History of previous fall
Prosthesis or specialty/prescription shoe
Sensory impairment (vision, hearing, balance, etc.)
None
Unknown
Other: PLEASE SPECIFY ____________________________________________________________________

10. What protocols/interventions were in place, or being used, to prevent falls for this patient/resident?
CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.

Assistive device (e.g., wheelchair, commode, cane, crutches, scooter, walker)
Bed or chair alarm
Bed in low position
Call light/personal items within reach
Change in medication (e.g., timing or dosing of current medication)
Fall alert
Floor mats
Non-slip footwear
Patient/resident and family education
Patient/resident situated close to the nurses’ station
Physical/occupational therapy
Siderails
Sitter
Supplemental, environmental, or area lighting (when usual facility lighting is considered insufficient)
Toileting regimen
Visible identification of patient/resident as being at risk for fall (e.g., Falling Star)
None
Unknown
Other: PLEASE SPECIFY ____________________________________________________________________

11. At time of the fall, was the patient/resident on medication known to increase the risk of fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

12. Was the medication considered to have contributed to the fall?
CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 3

Fall



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

13. Did restraints, bedrails, or other physical device contribute to the fall? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 3 of 3

Fall

Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

Patient Safety Event Report – Skilled Nursing Facility:

Yes - infection was determined to be present or incubating
on admission

b.
c.

No - infection developed during this stay
Unknown

STOP

This form is complete.

2. What type of HAI is being reported? CHECK ONE:

Urinary tract infection

Pneumonia

Primary bloodstream
infection

Clostridium difficile
infection (CDI)

Other type of infection
that developed during
admission

3. Was it a catheter-associated urinary tract infection (CAUTI)? CHECK ONE:

Yes

b.
c.

No
Unknown

ANSWER QUESTION 18

STOP

This form is complete.

4. Was the patient on a ventilator at the time of the event? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

STOP

This form is complete.

5. Was it a central line-associated bloodstream infection (CLABSI)? CHECK ONE:

Yes

b.
c.

No
Unknown

STOP

ANSWER QUESTION 7

STOP

This form is complete.

This form is complete.
ANSWER QUESTION 6

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 6

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

6. Which other type of infection? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Bone or joint infection
Central nervous system infection
Cardiovascular system infection
Eye, ear, nose, throat, or mouth infection
Gastrointestinal system infection - non-CDI
Lower respiratory tract infection (other than pneumonia)
Reproductive tract infection
Skin or soft tissue infection
Systemic infection
Other: PLEASE SPECIFY ____________________________________
ONLY IF EVENT INVOLVED A CLABSI, ANSWER QUESTIONS

STOP

This form is complete.

7 - 17

7. Was there a positive blood culture? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

STOP

This form is complete.

8. At the time the blood specimen yielding the positive culture was collected, what was the patient’s/resident’s status
with respect to a central line? CHECK ONE:

a.
b.

c.
d.

In place at the time of specimen
collection
Removed within 48 hours prior to
specimen collection

9. Which of the following were in place or removed within 48 hours
prior to specimen collection? CHECK ALL THAT APPLY:

Removed >48 hours prior to
specimen collection
Unknown

STOP

a.
b.
c.

Temporary central line, including PICC
Permanent central line
Unknown
This form is complete.

10. Did the patient/resident have both peripheral and central IV lines in place at the time of the event? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. Is the bloodstream infection clearly attributable to the
peripheral line? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 6

STOP

This form is complete.

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

12. Was the positive blood culture related to an infection at another site? CHECK ONE:

Yes

b.
c.

No
Unknown

STOP

This form is complete.

13. Was the blood culture positive for a recognized pathogen (e.g., S. aureus, Enterococcus, E. coli, Pseudomonas,
Klebsiella, Candida)? CHECK ONE:

Yes

b.
c.

No
Unknown

STOP

This form is complete.

14. Were two or more cultures drawn on separate occasions within two days of each other positive for a common skin
contaminant (e.g., S. epidermidis)? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

STOP

This form is complete.

15. At the time of the event, which of the following signs and symptoms were present? CHECK ALL THAT APPLY:

a.
b.
c.

Fever (>38 degrees C core)
Chills
Hypotension

None

IF AGE ≤1, ANSWER QUESTION 16,
IF AGE

65 ANSWER QUESTION 17, OTHERWISE

STOP

This form is complete.

STOP

This form is complete.

16. At the time of the event, which of the following signs and symptoms were present? CHECK ALL THAT APPLY:

a.
b.
c.
d.

Hypothermia (<36 degrees C core)
Apnea
Bradycardia
None

STOP

This form is complete.

17. At the time of the event, which of the following signs and symptoms were present? CHECK ALL THAT APPLY:

a.
b.
c.

Hypothermia (<36 degrees C core)
New mental status change
None
ONLY IF EVENT INVOLVED A CAUTI, ANSWER QUESTIONS

18 - 27

18. Was the diagnosis of urinary tract infection (UTI) confirmed by a positive urine culture? CHECK ONE:

a.
b.
c.

Yes
No - urine culture negative
No - urine culture not done

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 3 of 6

STOP

This form is complete.

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

19. At the time of the event what was the patient's/resident's age? CHECK ONE:

>1 year of
age

≤1 year of
age

20. At the time the urine specimen yielding
the positive culture was collected, what
was the patient’s/resident's status with
respect to an indwelling urinary
catheter? CHECK ONE:

Catheter was in place at time of
the urine specimen collection

21. At the time of the event, which, if any, of
the following signs and/or symptoms
were present with no other recognized
cause? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.

Fever >38 degree C core (if
patient less than 65 years of age)
Suprapubic tenderness
Costovertebral angle (CVA) pain
or tenderness
None
Unknown
GO TO QUESTION 25

Catheter had been in place but
was removed within 48 hours
prior to the urine specimen
collection

22. At the time of the event, which, if any, of
the following signs and/or symptoms
were present with no other recognized
cause? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.
h.

Fever >38 degrees C core (if
patient less than 65 years of age)
Suprapubic tenderness
Costovertebral angle (CVA) pain
or tenderness
Urgency
Frequency
Dysuria
None
Unknown
GO TO QUESTION 25

d.
e.

Catheter had been in place but
was removed >48
hours prior to the urine
specimen collection
Patient/resident had not had an
indwelling urinary catheter
during stay
Unknown

STOP

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 4 of 6

This form is complete.

Healthcare-associated Infection



Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

23. At the time the urine specimen yielding the positive culture was collected, what was the patient’s/resident's status
with respect to an indwelling urinary catheter? CHECK ONE:

a.
b.

c.
d.
e.

Catheter was in place at time of the urine
specimen collection
Catheter had been in place but was removed
within 48 hours prior to the urine specimen
collection

Catheter had been in place but was removed
>48 hours prior to the urine specimen
collection
Patient/resident had not had an indwelling
urinary catheter during stay
Unknown

24. At the time of the event, which, if any, of the following
signs and/or symptoms were present with no other
recognized cause? CHECK ALL THAT APPLY:

a.
b.
c.
d.
e.
f.
g.
h.
i.

STOP

Fever >38 degrees C core
Hypothermia (< 36 degrees C core)
Apnea
Bradycardia
Dysuria
Lethargy
Vomiting
None
Unknown

This form is complete.

25. What were the specific results of the positive urine culture? CHECK FIRST APPLICABLE:

≥105 colony-forming units
(CFU)/ml with no more than 2
species of uropathogen organisms

IF PATIENT/RESIDENT HAD NO UTI SYMPTOMS,
STOP
ANSWER QUESTION 27, OTHERWISE

≥103 and 105 CFU/ml with no
more than 2 species of
uropathogen microorganisms

26. Did the patient/resident have any of the following urinalysis
results? CHECK ALL THAT APPLY:

a.
b.

c.
d.
c.
d.
e.

More than two species of
uropathogen organisms
Fewer than ≥103 CFU/ml of
uropathogen organisms
Unknown

STOP

Postive dipstick for
leukocyte esterase and/
or nitrate
Pyuria (urine specimen
with ≥10 white blood
cells (WBC)/mm3 or
≥WBC/high power
field of unspun urine)
Microorganisms seen on
gram stain of unspun
urine
None

STOP

This form is complete.

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 5 of 6

Healthcare-associated Infection 

Event ID: __________________________
Initial Report Date (HERF Q6): __________________________

27. Did the patient/resident have a positive blood culture with at least one matching uropathogenic microorganism
[e.g., Gram-negative bacilli, Staphylococcus, yeasts, beta-hemolytic Streptococcus, Enterococcus, G. vaginalis,
Aerococcus urinae, Corynebacterium (urease positive)] to the urine culture? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

TIT/RESIDENT WAS 1 YEAR OLD OR YOUNGER, ANSWER QUESTION 25

AHRQ Common Formats – Skilled Nursing Facility Beta Version - February 2011 Release
Page 6 of 6

Healthcare-associated Infection

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

Patient Safety Event Report – Skilled Nursing Facility:

MEDICATION OR OTHER SUBSTANCE
Use this form to report any patient safety event or unsafe condition involving a substance such as a medication, vaccine,
nutrient, dietary supplement, medical gas, or contrast media. Do not complete this form if the event involves
appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known
drug-drug interaction). If the event involves a device, please also complete the Device or Supply Including Health
Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF).
Highlighted fields are collected for local facility and Patient Safety Organization (PSO) use. This information will not be
forwarded to the Network of Patient Safety Databases (NPSD).
1. What type of medication/substance was involved? CHECK ONE:

Medication

2. What type of medication?
CHECK ONE:

Prescription or over-thecounter
Compounded preparation

c.
d.

Investigational drug
Unknown

3. Please list all ingredients:
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Biological product

4. What type of biological product?
CHECK ONE:

a.
b.

Vaccine
Other biological product
(e.g., erythropoietin)

5. What was the lot number of the
vaccine?
LOT NUMBER

Nutritional product

Medical gas (e.g.,
oxygen, nitrogen,
nitrous oxide)

6. What type of nutritional product?
CHECK ONE:

a.
b.
c.
d.
e.

Patient/resident food
(not suspected in
drug-food
interactions)
Other substance:

STOP

PLEASE SPECIFY

_________________
AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 4

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

7. Which of the following best characterizes the event or unsafe condition? CHECK ONE:

a.
b.
c.
d.

Incorrect action (process failure or error) (e.g., such as administering
overdose or incorrect medication)
Unsafe condition
Adverse reaction in patient/resident to the administered substance
without any apparent incorrect action
Unknown

ANSWER QUESTIONS 17 - 21

This form is complete.

STOP

8. What was the incorrect action? CHECK ALL THAT APPLY:

a.
b.

Incorrect patient/resident
Incorrect medication/substance

c.
d.

Incorrect dose(s)
Incorrect route of administration

9. Which best describes the incorrect dose(s)? CHECK ONE:

Incorrect timing

10. Which best describes the incorrect timing? CHECK ONE:

a.
b.
c.
a.
b.

Overdose
Underdose
Missed or omitted dose
Too early
Too late

Incorrect rate

g.
h.

a.
Too quickly
b.
Too slowly
Incorrect duration of administration or course of therapy
Incorrect dosage form (e.g., sustained release instead of immediate release)
Incorrect strength or
concentration

Extra dose
Unknown

Unknown

11. Which best describes the incorrect rate? CHECK ONE:

d.
e.

Unknown

12. Which best describes the incorrect strength or concentration?
CHECK ONE:

a.
b.

Too high
Too low

Unknown

Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.

Expired or deteriorated
medication/substance

n.
o.

Medication/substance that is
known to be an allergen to
the patient/resident
Medication/substance that is
known to be contraindicated for
the patient/resident

13. What was the expiration date?

__ __ / __ __ / __ __ __ __
MM

YYYY

14. Was there a documented history of allergies or sensitivities to the
medication/substance administered? CHECK ONE:

a.
b.

Yes
No

Unknown

15. What was the contraindication (potential or actual interaction)?
CHECK ONE:

a.
Drug-drug
b.
Drug-food
c.
Drug-disease
d.
Other: PLEASE SPECIFY _____________________________
Incorrect patient/resident/family action (e.g., self-administration error)
Other: PLEASE SPECIFY ___________________________________________________________________

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 4

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

16. At what stage in the process did the event originate, regardless of the stage at which it was discovered?
CHECK ONE:

a.
b.
c.
d.
e.

Purchasing
Storing
Prescribing/ordering
Transcribing
Preparing

f.
g.
h.
i.
j.

Dispensing
Administering
Monitoring
Unknown
Other: PLEASE SPECIFY
____________________________________

QUESTIONS 17 - 23 DO NOT APPLY TO COMPOUNDED PREPARATION
FOR AN INCIDENT, ANSWER QUESTIONS 17-23
FOR A NEAR MISS, ANSWER QUESTIONS 17-22
FOR AN UNSAFE CONDITION, ANSWER QUESTIONS 17-21

Please provide the following medication details for any medications or other substances directly involved in the event or
unsafe condition.
17. Generic

name or
investigational
drug name

18. Brand name 19. Manufacturer 20. Strength or
(if known)

(if known)

concentration
of product

21. Dosage

form of
product

22. Was this

medication/
substance
prescribed for
this patient
/resident?

23. Was this

medication/
substance
given to this
patient
/resident?

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

a.
b.

Yes
No

IF THIS EVENT DID NOT INVOLVE AN INCORRECT ROUTE OF ADMINISTRATION

STOP

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 3 of 4

This form is complete.

Medication or Other Substance



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________
IF THE EVENT INVOLVED AN INCORRECT ROUTE OF ADMINISTRATION, ANSWER QUESTIONS 24 - 25

24. What was the intended route of administration?
CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

Cutaneous, topical application, including
ointment, spray, patch
Subcutaneous
Ophthalmic
Oral, including sublingual or buccal
Otic
Nasal
Inhalation
Intravenous
Intramuscular
Gastric
Rectal
Vaginal
Unknown
Other: PLEASE SPECIFY
_____________________________________

25. What was the actual route of administration
(attempted or completed)? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

Cutaneous, topical application, including
ointment, spray, patch
Subcutaneous
Ophthalmic
Oral, including sublingual or buccal
Otic
Nasal
Inhalation
Intravenous
Intramuscular
Gastric
Rectal
Vaginal
Unknown
Other: PLEASE SPECIFY
_____________________________________

Thank you for completing these questions.
OMB No. 0935-0143
Exp. Date 8/31/2011
Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 4 of 4

Medication or Other Substance

Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

Patient Safety Event Report – Skilled Nursing Facility:

PRESSURE ULCER
Use this form to report a pressure ulcer or suspected deep tissue injury that was 1) not present on admission (i.e., newlydeveloped) or 2) worsened during the patient’s/resident’s stay. Report only an event that occurred prior to patient/
resident discharge. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). Exclude arterial or
venous ulcers and diabetic foot ulcers. Highlighted fields are collected for local facility and Patient Safety Organization
(PSO) use. This information will not be forwarded to the Network of Patient Safety Databases (NPSD).
Note: For staging information refer to the MDS 3.0 Training Materials located on the Centers for Medicare & Medicaid
Services website: (https://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp).
1. What was the most advanced stage of the pressure ulcer being reported? CHECK ONE:

a.
b.

Stage 1
Stage 2

c.
d.

Stage 3
Stage 4

GO TO QUESTION 3

Unstageable (any type)

GO TO QUESTION 2

f.
g.

Mucosal, arterial, or venous ulcer or diabetic foot ulcer
Unknown

STOP

This form is complete.

STOP

This form is complete.

2. What was the type of the unstageable pressure ulcer? CHECK ONE:

a.
b.
c.
d.

Not stageable due to non-removable dressing/device
Not stageable due to coverage of wound bed by slough and/or eschar
Not stageable related to suspected deep tissue injury
Unknown

3. What was the status on admission of the Stage 3, 4, or unstageable pressure ulcer? CHECK ONE:

a.
b.
c.

Not present
Stage 1
Stage 2

d.
e.
f.

Stage 3
Stage 4
Unstageable

Unknown

GO TO QUESTION 4

STOP

This form is complete.
GO TO QUESTION 4

4. On admission to this facility, was a skin inspection documented? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 1 of 3

Pressure Ulcer



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

5. When was the first pressure ulcer risk assessment performed? CHECK ONE:

a.
b.
c.
d.
e.

6. What type of risk assessment was performed?
CHECK FIRST APPLICABLE:

a.
b.
c.

Formal assessment (e.g., Braden, Braden Q
(pediatric version), Norton, Waterlow)
Clinical assessment
Unknown

7. As a result of the assessment, was the
patient/resident documented to be at increased
risk for pressure ulcer? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

8. Was any preventive intervention implemented? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

9. What intervention(s) was used?
CHECK ALL THAT APPLY:

a.
b.
c.
d.

Pressure redistribution device
Repositioning
Nutritional support
Other: PLEASE SPECIFY
__________________________________

10. Was the use of a device or appliance involved in the development or advancement of the pressure ulcer? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

11. What was the type of device or
appliance? CHECK ONE:

a.
b.
c.
d.
e.
f.
g.

Anti-embolic device
Intraoperative positioning device
Orthopedic appliance (e.g., cast,
splint, orthotic)
Oxygen delivery device (e.g.,
nasal prongs, oxygen mask)
Restraints
Tube
Other: PLEASE SPECIFY
______________________

12. What type of tube?
CHECK ONE:

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 2 of 3

a.
b.
c.
d.
e.
f.

Endotracheal
Gastrostomy
Nasogastric
Tracheostomy
Indwelling urinary catheter
Other: PLEASE SPECIFY
______________________

Pressure Ulcer



Event ID: __________________________
Initial Report Date (HERF Q12): __________________________

13. During the patient’s/resident’s stay at this facility, did the patient/resident develop a secondary morbidity
(e.g., osteomyelitis or sepsis)? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

14. Was the secondary morbidity attributed to the presence of the pressure
ulcer? CHECK ONE:

a.
b.
c.

Yes
No
Unknown

AHRQ Common Formats - Skilled Nursing Facility Beta Version - February 2011 Release
Page 3 of 3

Pressure Ulcer

File Type	application/pdf
File Title	Complete Set of Common Formats Forms
Subject	Common formats, Forms, version, beta, complete set
Author	PSO Privacy Protection Center
File Modified	2011-06-28
File Created	2011-06-28