United States Health Information Knowledgebase

 

Summary of Initial Report (SIR)


Form ID: F3
Form Name: Summary of Initial Report (SIR)
Version: 1.2
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 [close call]) 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
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE75 Summary report date 1 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE112 Linked event ID Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE113 Reason for linking Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE78 Location (area of occurrence) of event or unsafe condition 2 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE81 Reporter type 3 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE84 Type of healthcare professional reporter 4 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE87 Description of additional details of event or unsafe condition after HERF 5 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE93 Near miss prevention action 6 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE96 Event associated with handover 7 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE102 Known contributing factors for event 8 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE105 Contributing factor(s) for event 9 Hospital Version 1.1, Hospital Version 1.2 03/31/2010 - -
DE109 NQF serious reportable event 10 Hospital Version 1.2 04/03/2012 - -
DE110 Type of NQF serious reportable event 11 Hospital Version 1.2 04/03/2012 - -
DE99 Incident preventability 12 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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