United States Health Information Knowledgebase


Summary of Initial Report (SIR)

Form ID: F3
Form Name: Summary of Initial Report (SIR)
Version: 1.1
Form Short Name: SIR
Synonym: SIR
Definition: The Summary of Initial Report (SIR) is used to collect summary information related to the Initial Report.
Setting: Hospitals, including outpatient pharmacies and outpatient departments located within the hospital
Language: U.S. English
Guide For Use: Use this form after all other forms applicable to this event (incident or near miss) or unsafe condition reported on the Healthcare Event Reporting Form (HERF) have been reviewed.

The SIR contains information that is, or may be, identifiable to the patient, reporter, provider, and facility. This information may be transmitted to a PSO as patient safety work product, but it is confidential and prohibited from disclosure as delineated in the Statute and Regulations. It may not be transmitted to the NPSD.
Comments: None defined at this time
Description Of Change: Not applicable for this release
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE75 Summary report date 1 1.1 03/31/2010 - -
DE78 Location (area of occurrence) of event or unsafe condition 2 1.1 03/31/2010 - -
DE112 Linked event ID 1.1 03/31/2010 - -
DE113 Reason for linking 1.1 03/31/2010 - -
DE81 Reporter type 3 1.1 03/31/2010 - -
DE84 Type of healthcare professional reporter 4 1.1 03/31/2010 - -
DE87 Description of additional details of event or unsafe condition after HERF 5 1.1 03/31/2010 - -
DE93 Near miss prevention action 6 1.1 03/31/2010 - -
DE96 Event associated with handover 7 1.1 03/31/2010 - -
DE102 Known contributing factors for event 8 1.1 03/31/2010 - -
DE105 Contributing factor(s) for event 9 1.1 03/31/2010 - -
DE106 Health information technology implicated in event 10 1.1 03/31/2010 - -
DE108 NQF serious reportable event 11 1.1 03/31/2010 - -
DE111 Type of NQF serious reportable event 12 1.1 03/31/2010 - -
DE99 Incident preventability 13 1.1 03/31/2010 - -
Effective Date: 03/31/2010
Until Date: - -
Update Date: - -
Submitting Organization: Agency for Healthcare Research and Quality (AHRQ)
Date of Submission: 03/31/2010
Responsible Organization: Agency for Healthcare Research and Quality (AHRQ)
Creator: John C. Moquin
Data Steward: Agency for Healthcare Research and Quality
References: No specific reference at this time
Administrative Status: Final
Administrative Status Date: 03/31/2010
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