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Common Format Forms

The term Common Formats is used to describe the technical requirements pertaining to collection and reporting of patient safety data, including all supporting material.

Common Formats delineate definitional and reporting specifications that allow healthcare providers to collect and submit standardized information regarding patient safety events. The Common Formats are not an attempt to replace any current mandatory reporting system, collaborative/voluntary reporting system, research-related reporting system, or other reporting/recording system.

The scope of Common Formats will apply to all patient safety concerns including:
  • incident - patient safety events that reached the patient, whether or not there was harm;
  • near miss or close call - patient safety events that did not reach the patient; and
  • unsafe condition - any circumstance that increases the probability of a patient safety event.

AHRQ has released Version 1.1 of the Common Formats with a defined focus on patient safety reporting for acute care hospitals. Future versions of the Common Formats will include other settings such as: skilled nursing facilities; ambulatory surgery centers; other ambulatory care settings, including physician and practitioner offices; and retail establishments such as pharmacies.


Blood or Blood Product


Device or Medical/Surgical Supply, including Health Information Technology (HIT)

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001  Which of the following best describes the event or unsafe condition?

002  What type of device was involved in the event or unsafe condition?

003  At the time of the event, was the device placed within the patient's tissue?

004  Did the event result in the device being removed?

005  What is the name (brand or generic) of the device, product, software, or medical/surgical supply?

006  What is the name of the manufacturer?

007  Which of the following identifiers are known?

008  What is the model number?

009  What is the software version?

010  What is the firmware version?

011  What is the serial number?

012  What is the lot or batch number?

013  What is the type of other unique product identifier?

014  What is the other unique product identifier?

015  What is the expiration date?

016  What is the Unique Device Identifier (UDI)?

017  What is the asset tag number?

018  Was a device intended for single use involved in the event or unsafe condition (including use of a reprocessed single-use device)?

019  Was a device intended for a single use reused in the event or unsafe condition?

020  Did the event or unsafe condition involve a medication or other substance?

021  Which of the following best characterizes the type of HIT device related to the event or unsafe condition?

022  Which component of the administrative/billing system?

023  Which type or component of the EHR?

024  Which of the following describes the circumstances involving the HIT device in the event or unsafe condition?

025  Which problem(s) resulted from the equipment/device function problem?

026  Which ergonomics or human/device interface issue(s)?


Fall


Healthcare Event Reporting Form (HERF)


Healthcare-associated Infection

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001  Was the infection determined to be present or incubating on admission?

002  Which of the following best describes the infection?

003  Was the person who determined the infection to be a healthcare-associated infection (HAI) a healthcare professional with specific training in infectious disease and/or infection control?

004  What type of HAI is being reported?

005  Was it central line-associated (CLABSI)?

006  Was it a ventilator-associated pneumonia (VAP - i.e., the patient had a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation)?

007  Was it catheter-associated (CAUTI)?

008  The SSI was classified as which of the following?

009  Which other type of infection?

010  Which type of central line?

011  The VAP was classified as which of the following?

012  What was the urinary catheter status at the time of specimen collection that was the basis for diagnosis of CAUTI?

013  The CAUTI was classified as which of the following?

014  At which inpatient location was the patient assigned when the specimen that met the infection criteria was collected, or when the first clinical evidence of CLABSI, VAP, or CAUTI appeared? If the infection developed within 48 hours of transfer from one location to one or more other locations within this facility, select the patient's first such inpatient location within the 48 hour period where the central line, urinary catheter, or ventilator was used.


Medication or Other Substance

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001  What type of medication/substance was involved?

002  What type of medication?

003  Please list all ingredients:

004  What type of biological product?

005  What was the lot number of the vaccine?

006  What type of nutritional product?

007  Which of the following best characterizes the event?

008  What was the incorrect action?

009  Which best describes the incorrect dose(s)?

010  Which best describes the incorrect timing?

011  Which best describes the incorrect rate?

012  Which best describes the incorrect strength or concentration?

013  What was the expiration date?

014  Was there a documented history of allergies or sensitivities to the medication/substance administered?

015  What was the contraindication (potential or actual interaction)?

016  At what stage in the process did the event originate, regardless of the stage at which it was discovered?

017  Generic name or investigational drug name

018  Ingredient RXCUI (if known)

019  Brand name (if known)

020  Brand name RXCUI (if known)

021  Manufacturer (if known)

022  Strength or concentration of product

023  Clinical drug component RXCUI (if known)

024  Dosage form of product

025  Dose form RXCUI (if known)

026  Was this medication/substance prescribed for this patient?

027  Was this medication/substance given to this patient?

028  What was the intended route of administration?

029  What was the actual route of administration (attempted or completed)?


Patient Information Form (PIF)


Perinatal


Pressure Ulcer


Summary of Initial Report (SIR)


Surgery or Anesthesia

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001  Describe briefly the procedure associated with this event:

002  Enter ICD-9-CM or ICD-10-CM procedure code associated with this event (if available ):

003  What was the patient's documented American Society of Anesthesiologists (ASA) Physical Classification System class?

004  Was the procedure performed as an emergency?

005  Which combination of anesthesia and sedation was used?

006  What type of anesthesia?

007  What type of anesthesia?

008  What was the level of sedation?

009  What was the level of sedation?

010  What was the length of time from induction of anesthesia to the end of anesthesia?

011  Who administered (or, if the event occurred prior to administration of anesthesia, person who was scheduled to administer) the anesthesia or sedation?

012  Was there supervision by an anesthesiologist?

013  When was the event discovered?

014  What was the medical or surgical specialty of the provider or team who performed the procedure?

015  What best describes the event?

016  Which of the following major complications occurred?

017  Which of the following best describes the respiratory support provided?

018  Was the surgical event a retained object?

019  What type of object was retained?

020  Was a count performed for the type of object that was retained?

021  After counting, what was the reported count status?

022  Was an x-ray obtained before the end of the procedure to detect the retained object?

023  Was the retained object radiopaque (i.e., detectable by x-ray)?

024  Which of the following best characterizes the surgical event?

025  Which of the following occurred?

026  What was incorrect about the surgical or invasive procedure?

027  If the event involved anesthesia, which of the following best characterizes the event?

028  Which of the following best characterizes the airway management problem?


Venous Thromboembolism



Blood or Blood Product


Device or Medical/Surgical Supply


Fall


Healthcare Event Reporting Form (HERF)

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001  What is being reported?

002  Was there any evidence of harm to a patient at the time of this report?

003  Event Discovery Date:

004  Event Discovery Time:

005  Briefly describe the event that occurred or unsafe condition:

006  Briefly describe the location where the event occurred or where the unsafe condition exists:

007  Which of the following categories are associated with the event or unsafe condition? For each category selected below, except ´other´, please complete the corresponding category-specific form. All categories include reporting of incidents. Any category with + also includes reporting of near misses. Any category with * also includes reporting of unsafe conditions.

008  How many patients did the incident reach?

009  Patient´s Name: First Middle Last

010  Patient´s Date of Birth:

011  Medical Record #:

012  Patient´s Gender:

013  Patient´s Name: First Middle Last

014  Patient´s Date of Birth:

015  Medical Record #:

016  Patient´s Gender:

017  Report date:

018  Anonymous Reporter

019  Reporter´s Name: First, Middle, Last

020  Telephone Number:

021  Email Address:

022  Reporter´s Job or Position:


Healthcare-associated Infection

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001  Was the infection determined to be present or incubating on admission?

002  Which of the following best describes the infection?

003  Was the person who determined the infection to be a healthcare-associated infection (HAI) a healthcare professional with specific training in infectious disease and/or infection control?

004  What type of HAI is being reported?

005  Was it central line-associated (CLABSI)?

006  Was it a ventilator-associated pneumonia (VAP - i.e., the patient had a device to assist or control respiration continuously through a tracheostomy or by endotracheal intubation)?

007  Was it catheter-associated (CAUTI)?

008  The SSI was classified as which of the following?

009  Which other type of infection?

010  Which type of central line?

011  The VAP was classified as which of the following?

012  What was the urinary catheter status at the time of specimen collection that was the basis for diagnosis of CAUTI?

013  The CAUTI was classified as which of the following?

014  At which inpatient location was the patient assigned when the specimen that met the infection criteria was collected, or when the first clinical evidence of CLABSI, VAP, or CAUTI appeared? If the infection developed within 48 hours of transfer from one location to one or more other locations within this facility, select the patient´s first such inpatient location within the 48 hour period where the central line, urinary catheter, or ventilator was used.


Medication or Other Substance

View Form Detail

001  What type of medication/substance was involved?

002  What type of medication?

003  Please list all ingredients:

004  What type of biological product?

005  What was the lot number of the vaccine?

006  What type of nutritional product?

007  Which of the following best characterizes the event?

008  What was the incorrect action?

009  Which best describes the incorrect dose(s)?

010  Which best describes the incorrect timing?

011  Which best describes the incorrect rate?

012  Which best describes the incorrect strength or concentration?

013  What was the expiration date?

014  Was there a documented history of allergies or sensitivities to the medication/substance administered?

015  What was the contraindication (potential or actual interaction)?

016  At what stage in the process did the event originate, regardless of the stage at which it was discovered?

017  Generic name or investigational drug name

018  Brand name (if known)

019  Manufacturer (if known)

020  Strength or concentration of product

021  Dosage form of product

022  Was this medication/substance prescribed for this patient?

023  Was this medication/substance given to this patient?

024  What was the intended route of administration?

025  What was the actual route of administration (attempted or completed)?


Patient Information Form (PIF)


Perinatal


Pressure Ulcer


Summary of Initial Report (SIR)


Surgery or Anesthesia

View Form Detail

001  Describe briefly the procedure associated with this event:

002  Enter ICD-9-CM procedure code associated with this event:

003  What was the patient´s documented American Society of Anesthesiologists (ASA) Physical Classification System class?

004  Was the procedure performed as an emergency?

005  When was the event discovered?

006  What was the total length of the procedure (i.e., induction of anesthesia to the end of anesthesia)?

007  What type of anesthesia or sedation was used?

008  What was the level of sedation?

009  Who administered (or, if the event occurred prior to administration of anesthesia, person who was scheduled to administer) the anesthesia?

010  Was there supervision by an anesthesiologist?

011  What was the medical or surgical specialty of the provider who performed the procedure?

012  What best describes the event?

013  Which of the following major complications occurred?

014  Which of the following best describes the respiratory support provided?

015  Was the surgical event an unintentionally retained object?

016  What type of object was retained?

017  Was a count performed for the type of object that was retained?

018  After counting, what was the reported count status?

019  Was an x-ray obtained before the end of the procedure to detect the retained object?

020  Was the retained object radiopaque (i.e., detectable by x-ray)?

021  Which of the following best characterizes the surgical event?

022  Which of the following occurred?

023  What was incorrect about the surgical or invasive procedure?

024  If the event involved anesthesia, which of the following best characterizes the event?

025  Which of the following best characterizes the airway management problem?


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