United States Health Information Knowledgebase

 

Healthcare Event Reporting Form (HERF)


Form ID: F1
Form Name: Healthcare Event Reporting Form (HERF)
Version: 1.1
Form Short Name: HERF
Synonym: HERF
Definition: The Healthcare Event Reporting Form (HERF) captures information on incidents, near misses, 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 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 for this release
Data Element ID Sort Data Element Name Sort Question Number Sort Version Sort Effective Date Sort Until Date Sort
DE3 Report type 1 1.1 03/31/2010 - -
DE6 Patient harm 2 1.1 03/31/2010 - -
DE9 Event discovery date 3 1.1 03/31/2010 - -
DE58 Event discovery time 4 1.1 03/31/2010 - -
DE15 Description of event or unsafe condition 5 1.1 03/31/2010 - -
DE18 Description of location of event or unsafe condition 6 1.1 03/31/2010 - -
DE21 Category(s) associated with event or unsafe condition 7 1.1 03/31/2010 - -
DE24 Number of patients 8 1.1 03/31/2010 - -
DE46 Patient name 9 1.1 03/31/2010 - -
DE47 Patient date of birth 10 1.1 03/31/2010 - -
DE49 Patient medical record number 11 1.1 03/31/2010 - -
DE42 Patient gender 12 1.1 03/31/2010 - -
DE46 Patient name 13 1.1 03/31/2010 - -
DE47 Patient date of birth 14 1.1 03/31/2010 - -
DE49 Patient medical record number 15 1.1 03/31/2010 - -
DE42 Patient gender 16 1.1 03/31/2010 - -
DE30 Initial report date 17 1.1 03/31/2010 - -
DE33 Identity of reporter 18 1.1 03/31/2010 - -
DE50 Reporter name 19 1.1 03/31/2010 - -
DE52 Reporter phone number 20 1.1 03/31/2010 - -
DE53 Reporter email 21 1.1 03/31/2010 - -
DE36 Reporter job or position 22 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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