Safety Event Report Form

CONFIDENTIAL/NOT PART OF THE MEDICAL RECORD

This is a quality improvement document.

This is a privileged and confidential peer review document per the Healthcare Quality Improvement Act of 1986 (42 U.S.C. Section 11101 et seq.).

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* 1. Who is completing this Safety Event Report form?

Name *

Email Address

Phone Number

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* 2. Facility Name (do not abbreviate):

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* 3. Facility ID Number (if known):

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* 4. Therapy Program Manager's Name:

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* 5. Vice President of Operations or Regional Manager's Name:

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* 6. Region (Michigan, Ohio, etc.):

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* 7. Name(s) of Involved Ovation Employee(s):

Ovation Employee Name

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* 8. Therapy Discipline(s) Involved (check all that apply)

COTA

PTA

SLP

Other (please specify)

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* 9. Involved Individual:

Patient

Visitor

Student/Volunteer

Other (please specify)

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* 10. Name of Patient or Involved Individual:

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* 11. Age of Patient or Involved Individual:

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* 12. Witness Information:

Name, Company, Title, Phone Number:

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* 13. Date and Time of Incident:

Date / Time

Date

Time

AM/PM

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* 14. Location where event occurred (please check all that apply):

Bathroom

Hallway

Patient Room

Dining Room

Therapy Gym

Other (please specify)

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* 15. Severity of Incident:

Category A: Circumstances that could cause injury.

Category B: Event occurred but did not reach the involved individual.

Category C: Event occurred that reached the involved individual but caused no harm.

Category D: Event occurred that required monitoring or testing but caused no harm.

Category E: Event occurred that caused minimal or temporary harm and intervention.

Category F: Event occurred that caused initial or prolonged hospitalization.

Category G: Event occurred that may have caused permanent harm.

Category H: Event occurred that required an intervention to sustain life.

Category I: Event occurred that may have resulted in or contributed to death.

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* 16. Event Type (check all that apply):

Allegation of Abuse

Back Injury

Choking

Device or Equipment Failure

Device User Error

Elopement

Fall While Ambulating

Fall Related to Bathing

Fall Related to Toileting

Fall Related to Transferring

Fall Related to Therapy Activity

Visitor Fall

Medication Issue

Muscle Sprain/Strain

New Onset of Pain

Skin Tear

Pressure Injury

Burn

Other (please specify)

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* 17. Was Indvidual Identified as a Fall Risk?

Yes

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* 18. Were Fall Precautions in Place?

Yes

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* 19. Was Gait Belt in Use at the Time of the Incident?

Yes

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* 20. If Incident was a Fall, was it an Assisted Fall?

Yes

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* 21. Facts of the Incident as They Happened (please be clear and detailed):

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* 22. Was Nursing Notified?

Yes

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* 23. Was the Physician Notified?

Yes

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* 24. Was Facility Reporting Process Followed?

Yes

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* 25. Was Follow Up Treatment Required?

Yes

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* 26. Was the Individual Transferred to the Hospital?

Yes

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* 27. What changes have been/could be put in place to prevent this from happening again?

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* 28. I certify that the above information is true and accurate to the best of my knowledge.

I agree