|Data Element ID:||DE21|
|Name:||Category(s) associated with event or unsafe condition|
|Version:||Hospital Version 1.1, Hospital Version 1.2|
|Data Element ISO Name:||Event or unsafe condition-Category,CD|
|Definition:||Documentation of the category of event that was being reported to include an incident, near miss or unsafe condition.|
|Question:||Which of the following categories are associated with the event or unsafe condition?|
|Form Name:||Healthcare Event Reporting Form (HERF)|
|Setting:||Hospitals, including outpatient pharmacies and outpatient departments located within the hospital|
|Comments:||None defined at this time|
|Description of Change:||
Added A44 (b) "Device or Medical/Surgical Supply, including Health Information Technology (HIT)";
Removed A45 (b) "Device or Medical/Surgical Supply" from the answer value set;
Added A64 (j) "Venous Thromboembolism" to the answer value set;
Modified "Device or Medical/Surgical Supply" module to include Health Information Technology (HIT). Added "Venous Thromboembolism" as another patient safety module for event reporting;
Changed Maximum Length of characters for free text from "500" to "2000"
|Go-To Logic:||Refer to Common Formats Flow Charts|
|Guide For Use:||
Additional Common Formats have been defined for nine specified categories of patient safety concerns. For the patient safety concern you are reporting, please select all of the categories in the list that apply to that concern, and, for each category selected, except 'Other', complete the corresponding category-specific form. All categories include reporting of incidents. The 'Blood or Blood Product', 'Device or Medical/Surgical Supply including HIT', 'Medication or Other Substance', 'Surgery or Anesthesia', and 'Other' categories include reporting of near misses. The 'Blood or Blood Product', 'Device or Medical/Surgical Supply including HIT', and 'Medication or Other Substance' categories include reporting of unsafe conditions.
Select 'Blood or Blood Product' if the concern you are reporting involved the processing and/or administration of blood or a blood product.
Select 'Device or Medical/Surgical Supply including HIT' if the concern you are reporting involved a device failure or incorrect use of a device. A device includes an implant, medical equipment, or a medical/surgical supply (including a disposable product).
Select 'Fall' if the concern you are reporting involved a sudden, unintended, uncontrolled downward displacement of a patient's body to the ground or other unintended surface and the concern was an incident, i.e., not a near miss or unsafe condition.
Select 'Healthcare-associated Infection' if the concern you are reporting was a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was acquired during the course of receiving treatment for other conditions within a healthcare setting and the concern was an incident, i.e., not a near miss or unsafe condition.
Select 'Medication or Other Substance' if the concern you are reporting involved a substance such as a medication, vaccine, nutrient, dietary supplement or medical gas.
Select 'Perinatal' if the incident you are reporting involved an adverse outcome occurring during the perinatal period to the mother, fetus(es), or neonate(s) and the incident involved the birthing process or an intrauterine procedure that occurred prior to the onset of labor. The perinatal period extends from the 20th week of gestation through 4 weeks (28 days) post-partum. The neonatal period extends from birth until the end of the perinatal period.
Select 'Pressure Ulcer' if the concern you are reporting involved a pressure ulcer or deep tissue injury that was not present on admission or that worsened during the patient's stay and the concern was an incident, i.e., not a near miss or unsafe condition.
Select 'Surgery or Anesthesia' if the concern you are reporting involved a surgical or other invasive procedure (e.g., colonoscopy) or the administration of anesthesia and the concern was an incident or near miss, i.e., not an unsafe condition.
Select 'Venous Thromboembolism' if the concern you are reporting involved one or both of the following: 1) a deep vein thrombosis (DVT) or 2) a pulmonary embolism (PE).
Select 'Other' if the concern you are reporting does not belong to any of the listed categories. If so, please describe the event in a few words.
|HL7 Data Type:||Concept Descriptor (CD)|
|Maximum Length:||3 (2000 for free text associated with 'Other: Please specify' response.)|
|Answer Code||Answer ID||Answer Value||Code System||Code System Name|
|A42||a||Blood or Blood Product||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A44||b||Device or Medical/Surgical Supply, including Health Information Technology (HIT)||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A48||c||Fall||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A51||d||Healthcare-associated Infection||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A54||e||Medication or Other Substance||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A57||f||Perinatal||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A60||g||Pressure Ulcer||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A63||h||Surgery or Anesthesia (includes invasive procedure)||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A64||i||Venous Thromboembolism||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|A66||j||Other: Please specify||2.16.840.1.113883.3.263.1.12||AHRQ Common Formats|
|Until Date:||- -|
|Source:||Agency for Healthcare Research and Quality|
|Submitting Organization:||Agency for Healthcare Research and Quality (AHRQ)|
|Date of Submission:||- -|
|Responsible Organization:||Agency for Healthcare Research and Quality (AHRQ)|
|Creator:||Amy Helwig, MD, MS|
|Data Steward:||Agency for Healthcare Research and Quality (AHRQ)|
|References:||No specific reference at this time|
|Rationale for Change:||
Answer Value clarification;
Increased narrative field size to accommodate more information
|Administrative Status Date:||04/03/2012|