Patient Safety Reporting System

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File A Report

Date of occurrence:
Time of occurrence:
Brief description:

Reporter Information & Event Background
Were you a patient or an employee?	Patient Employee
If employee, your position:
What is your current position?
How many years of health care experience do you have?
How many years have you worked at this hospital?
How many years have you worked in your current position?
What shift were you working when the incident occurred?
Was this your regular shift?	Yes          No
When did the event occur?

Event Location
Where did the event occur?

Environmental Factors
What environmental factors contributed to the event?

Other Factors
Were there any other factors involved?

Event Description
Keeping in mind the topics shown below, discuss those which you feel are relevant and anything else you feel is important. Include what you believe really CAUSED the problem, and what can be done to PREVENT a recurrence, or CORRECT the situation.
Chain of Events	Human Performance Factors
- how the problem arose	- perceptions, judgments, decisions
- how it was discovered	- actions or inactions
- contributing factors	- factors affecting the quality of human performance
- corrective actions

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