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Healthcare Event Reporting Form (HERF)


Form ID: F1
Form Name: Healthcare Event Reporting Form (HERF)
Version: 1.2
Form Short Name: HERF
Synonym: HERF
Definition: The Healthcare Event Reporting Form (HERF) captures information on incidents, near misses (close calls), and unsafe conditions. This form is analogous to incident reports commonly used in hospitals today. It contains structured questions and allows for a brief narrative to document the precise details of the event or unsafe condition. The HERF solicits only the most basic information about an event or unsafe condition and is intended to start a reporting process that is completed using other generic and event-specific forms. For perinatal events, the HERF contains basic patient identifiers for both the mother and neonate.
Setting: Hospitals, including outpatient pharmacies and outpatient departments located within the hospital
Language: U.S. English
Guide For Use: Use this form to report either a patient safety event or unsafe condition. The term event includes both an incident that reaches the patient and a near miss (close call) that did not.
HERF is designed to be completed by the individual who witnessed, first discovered, or is most familiar with the details of the event.
The HERF 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
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE30 Initial report date 1 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE3 Report type 2 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE9 Event discovery date/time (date) 3 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE9 Event discovery date/time (time) 4 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE15 Description of event or unsafe condition 5 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE18 Description of location of event or unsafe condition 6 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE21 Category(s) associated with event or unsafe condition 7 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE46 Patient name 8 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE47 Patient date of birth 9 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE49 Patient medical record number 10 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE42 Patient gender 11 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE34 Neonate name 12 Hospital Version 1.2 04/03/2012 - -
DE37 Neonate date of birth 13 Hospital Version 1.2 04/03/2012 - -
DE40 Neonate medical record number 14 Hospital Version 1.2 04/03/2012 - -
DE43 Neonate gender 15 Hospital Version 1.2 04/03/2012 - -
DE33 Identity of reporter 16 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE50 Reporter's name 17 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE52 Telephone number 18 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE53 Email address 19 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE36 Reporter's job 20 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
Effective Date: 04/01/2012
Until Date: - -
Update Date: 04/24/2013
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
References: Not Applicable
Administrative Status: Final
Administrative Status Date: 01/24/2014
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