12 Site Data Submission Form

Attachment M - Diagnostic Safety Event Report

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

SITE DATA SUBMISSION FORM

Please complete the following information about diagnostic safety events for (ORGANIZATION). It should take no longer than 60 minutes to complete.

Instructions: PLEASE FILL IN aggregated numbers for given site with no potentially identifiable factor

linked to any other potentially identifiable factor. Bold = required fields

Aggregated Data Elements If numbers don’t add up to total, please use notes field to explain discrepancy.	Value	Open-ended notes field for comments
Site ID
Site name
Site type (Check one): Hospital Children’s hospital Ambulatory clinic Clinic network
Name(s) of person filling out form:
Email (to use only for questions):
Reporting period start date: MM/YY
Reporting period end: MM/YY

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 60 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. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. 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, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to the AHRQ MEPS Project Director at [email protected].

Aggregated Data Elements If numbers don’t add up to total, please use notes field to explain discrepancy.	Value	Open-ended notes field for comments
Total patients at site: Race/Ethnicity: % Hispanic % White % Black % Asian/API % Other Primary Language: % English: % Non-English primary language:
Number of diagnostic safety events identified Total identified: By source: Patient complaints: Patient surveys: EHR: Clinician reported: Other source:
Number of diagnostic safety events identified Total identified: by Diagnostic safety event type: Missed: Delayed: Wrong: Degree of error: Near miss: Mild: Moderate: Serious: Harm: None: Mild: Moderate: Severe no mortality: Severe w/ mortality:
ROWS BELOW ARE NOT REQUIRED INFORMATION; PLEASE FILL IN WHAT YOU ARE ABLE:
Number of diagnostic safety events identified Total identified: by Number reviewed by QI team: Number reviewed using a standardized tool Revised Safer Dx: Diagnostic Error Evaluation Research (DEER): Fishbone Diagram for Diagnostic Errors: Common Format for Event Reporting Diagnostic Safety: Other: Of reviewed events, number of events with learnings for quality improvement:
Number of patients involved in diagnostic safety events, Total patients involved in diagnostic safety events by Ethnicity (Hispanic/non-Hispanic) Race (white, Black, Asian/API, other) Sex/gender (female, male, non-binary, prefer not to say) Age categories (<1, 1-5, 6-12, 13-17, 18-39, 40-64, 65-79, 80+) Primary Language (English/non-English) Diagnosis category, such as Major Diagnosis Category (MDC) (NOTE: THE RESPONSE CATEGORIES BELOW ARE SHOWN AS AN EXAMPLE; FINAL SET MAY COMBINE CATEGORIES TO REDUCE OPTIONS; NOT TO EXCEED 26 OPTIONS). MDC 00 Ungroupable MDC 01 Nervous System MDC 02 Eye MDC 03 Ear, Nose, Mouth & Throat MDC 04 Respiratory System MDC 05 Circulatory System MDC 06 Digestive System MDC 07 Hepatobiliary System & Pancreas MDC 08 Musculoskeletal System & Connective Tissue MDC 09 Skin, Subcutaneous Tissue & Breast MDC 10 Endocrine, Nutritional & Metabolic MDC 11 Kidney & Urinary Tract MDC 12 Male Reproductive System MDC 13 Female Reproductive System MDC 14 Pregnancy, Childbirth & the Puerperium MDC 15 Newborns & Other Neonates with Conditions Originating in Perinatal Period MDC 16 Blood, Blood Forming Organs, Immunologic Disorders MDC 17 Myeloproliferative Diseases & Disorders, Poorly Differentiated Neoplasms MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified Sites MDC 19 Mental Diseases & Disorders MDC 20 Alcohol/Drug Use & Alcohol/Drug Induced Organic Mental Disorders MDC 21 Injuries, Poisonings & Toxic Effects of Drugs MDC 22 Burns MDC 23 Factors Influencing Health Status & Other Contacts with Health Services MDC 24 Multiple Significant Trauma MDC 25 Human Immunodeficiency Virus Infections
Settings of diagnostic safety events (for hospitals only), by Unit These may not add up to the total Inpatient ED ICU PACU Labor & delivery Other1 – please provide unit name: Other2 – please provide unit name: