Form #4 Form #4 Health care provider follow-up form

CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY: Administrative Script When Matching Consumer Submission with Incident Reporting System

T

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

able: 3-8

Module 8:

Administrative Script When Matching Consumer Submission with Incident Reporting System

8.1 CRSO Status

 Screened

 Exclusion reason:

 Age

 Grievance

 Service complaint

 Other [FREE TEXT]

 Audited (Free Text Reviewed and Sanitized)

 [FREE TEXT]

 [FREE TEXT]

 [FREE TEXT]

 [FREE TEXT]

 [FREE TEXT]

 Finalized

Community [DROP DOWN]

Not Applicable [AUTO SELECT]

Community 1

Community 2

1. Was patient’s report edited based on follow up with reporter?

1. Yes

2. No, we spoke to reporter and there were no changes

3. No, we were not able to contact the reporter

4. No, we did not have permission to contact the reporter

1. Patient gave permission to speak to the facility

1. Yes

2. No (If no, do not proceed)

8.2 Was the Health Care Facility (HCF) aware of the patient safety concern?

1. Yes

2. No

3. Unknown

8.3 Was it reported as a patient safety event?

1. Yes

2. No

3. Unknown

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. 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-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

8.4 Who reported the event or unsafe condition?

1. Healthcare professional (If selected, go to 7.4.1)

8.4.1. What is the type of healthcare professional?

1. Doctor, dentist (including student)

2. Nurse, nurse practitioner, physician assistant (including student or trainee)

3. Pharmacist, pharmacy technician (including student)

4. Allied health personnel, paramedic

b. 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

c. Emergency service personnel, including police officer, fire fighter, or other emergency service officer

d. Patient/relative/volunteer/caregiver/home assistant

e. Anonymous or unknown

8.5 Was a Root Cause Analysis (RCA) completed?

1. Yes

2. No

3. Unknown

8.6 Are any contributing factors to the event known?

a. Yes (If yes, go to 8.6.1)

b. No

c. Unknown

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

 Team coordination factors

1. Communication: supervisor to staff

2. Communication: staff to patient

3. Communication: among staff or team members

4. Clinical Supervision

5. Managerial Supervision

6. Scheduling conflicts

7. Heavy workload

8. Shift change

 Staff/individual factors

1. Adherence to policy, protocols, or orders

2. Cognitive factors

3. Competence (qualifications, experience)

4. Familiarity with environment

5. Familiarity with policy and procedure

6. Fatigue

7. Health issues

8. Inattention

9. Long work hours

10. Stress

11. Training

 Operating environment factors

1. Biohazards and sharps management

2. Equipment/device availability

3. Equipment/device design

4. Equipment/device function

5. Equipment/device maintenance

6. Housekeeping

7. Physical surroundings (e.g.. lighting, noise)

8. Unlocked/unsecured area

9. Interruptions (human)

 Workflow/Task Factors

1. Bed capacity

2. Delay in response to code

3. Delay in discharges

4. Staffing ratios

5. Transport delays

6. Consent error/not completed

7. Completion of patient/resident assessment

8. Data legibility

9. Data Availability

10. Data Accuracy

11. Management of test results

12. Order/requisition difficulties

 Patient/Resident Factors

1. Agitated/aggressive

2. Confused/disoriented

3. Impaired hearing or speech

4. Language barrier

5. Refusal of care or non-compliance

6. Unresponsive

 Management/organization Factors

1. Clarity of policy/procedure

2. Culture of safety management

3. Empowerment (eg any healthcare provider can call a code)

4. Presence of policy/procedure

5. Resource constraints (financial or human)

 Other

1. Please Specify [FREE TEXT]

8.7 Lessons Learned?

[FREE TEXT]