Form CDC 57.305 CDC 57.305 Hemovigilance Module Incident

[NCEZID] The National Healthcare Safety Network (NHSN)

57.305_HV Incident_BLANK

57.305 Hemovigilance Incident

OMB: 0920-0666

Document [docx]
Download: docx | pdf

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn


Hemovigilance Module

Incident


*Required for saving

*Facility ID#: _________________

NHSN Incident #: __________

Local Incident # or Log #: _________

Discovery

*Date of discovery: __ __ /__ __ / __ __ __ __

*Time of discovery: __ __ : __ __(HH:MM)

Time approximate

Time unknown

*Where in the facility was the incident discovered?

_____________________________________

*At what point in the process was the incident first discovered? (check one)

Product check-in

Order entry

Sample testing

Satellite storage

Product storage

Sample collection

Product manipulation

Product administration

Inventory management

Sample handling

Request for pick-up

Post-transfusion review/audit

Product/test request

Sample receipt

Product issue

Other ___________________

*How was the incident first discovered? (check one)

Visual inventory review

Observation by staff of unit/reagent/sample/equipment

Routine audit or supervisory review

Comparison of product label to patient information

Computer system alarm or warning

Comparison of product label to physician order

Comparison of sample to paperwork

When checking patient ID band

Repeat or sample re-testing

Notification or complaint from floor (nurse, MD, etc.)

Historical record/previous type check

When product/units returned to lab

Communication from lab to floor

Patient transfusion reaction

Human ‘lucky catch’

Other (specify) _________________________________

Occurrence

*Date initial incident occurred: __ __ /__ __ / __ __ __ __

*Time initial incident occurred: __ __ : __ __(HH:MM)

Time approximate

Time unknown

Incident summary: (500 characters max)

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________


Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).


Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).



*Incident code(s): (max 20) Use NHSN incident codes in the surveillance protocol.

Incident Code

Occurrence Location

Incident Code

Occurrence Location

1

__ __ __ __

______________________

11

__ __ __ __

______________________

2

__ __ __ __

______________________

12

__ __ __ __

______________________

3

__ __ __ __

______________________

13

__ __ __ __

______________________

4

__ __ __ __

______________________

14

__ __ __ __

______________________

5

__ __ __ __

______________________

15

__ __ __ __

______________________

6

__ __ __ __

______________________

16

__ __ __ __

______________________

7

__ __ __ __

______________________

17

__ __ __ __

______________________

8

__ __ __ __

______________________

18

__ __ __ __

______________________

9

__ __ __ __

______________________

19

__ __ __ __

______________________

10

__ __ __ __

______________________

20

__ __ __ __

_____________________

MS 99

Miscellaneous, specify _________________________________________________

Job function of the worker(s) involved in the incident: (max 6) Use NHSN occupation codes in the protocol.

__ __ __

__ __ __

__ __ __

__ __ __

__ __ __

__ __ __

Other

Other (OTH), specify __________________________

Worker unknown

*Incident result: (check one)

1 – Product transfused, reaction

3 – No product transfused, unplanned recovery

2 – Product transfused, no reaction

4 – No product transfused, planned recovery

*Product action: (check all that apply)

Not applicable

Product retrieved and returned to inventory

Product retrieved and destroyed

^Single or multiple units destroyed?

Single unit:

Code system used:

ISBT-128

Codabar

Unit #: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

OR

Component code: __ __ __ __ __

Multiple units: (select code system used)

ISBT-128

Codabar

Component code: __ __ __ __ __

Number of units: ____

ISBT-128

Codabar

Component code: __ __ __ __ __

Number of units: ____

ISBT-128

Codabar

Component code: __ __ __ __ __

Number of units: ____

Product issued but not transfused

Product transfused

^Was a patient reaction associated with this incident?

Yes

No

^Patient ID#(s):

__________

__________

__________

__________

__________




*Record/other action: (check all that apply)

Record corrected

Floor/clinic notified

Attending physician notified

Additional testing

Patient sample re-collected

Other (specify) __________________

Investigation Results

*Did this incident receive root cause analysis?

Yes

No

Custom Fields

Label


Label


________________

__ __/__ __/__ __ __ __

________________

__ __/__ __/__ __ __ __

________________

___________________

________________

___________________

________________

___________________

________________

___________________

________________

___________________

________________

___________________

________________

___________________

________________

___________________

Comments (2000 characters max)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


CDC 57.305, Rev. 5, v8.4

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