REPORT AN ADVERSE MEDICAL EVENT (v2)

WELCOME

Most reporting systems for adverse medical events are concerned with collecting information for use by healthcare providers. Our survey is designed to answer questions that are important to patients. What procedures are associated with harm? Why? What are the common factors patients see as leading to harm, and how do healthcare providers respond? This is a way for patients to report their experience as they have lived it, and to know that their report will be counted.

The survey is divided into sections covering various categories of medical adverse events. Answers in the relevant categories can be as brief or as lengthy as you would like them to be. Boxes simply can be checked but we encourage you to use the narrative sections to share vital details, observations and suggestions. Those who prefer not to fill out a survey can click through and leave a full narrative in the space provided at the end. If you have had more than one unrelated adverse event or hospitalization, you are welcome to fill out more than one survey. In addition, this survey is both historical and ongoing. Adverse events can be reported from any time period.

Unless you explicitly give it to us, we do not collect your computer IP number, contact information, or location. Reports are tallied by state or province where that information is available, and data will be aggregated nationally. With the understanding that this is a voluntary survey and does not pretend to be scientific, we make our findings available at www.empoweredpatientcoalition.org.

Please click below to take the survey.

1. Personal Information (OPTIONAL)

Personal Information (OPTIONAL) Name:
City/Town:
State/Province:
Country:
Email Address:
Phone Number:

2. May we contact you regarding your survey?

May we contact you regarding your survey? Yes

3. State, province, or country where incident occurred

State, province, or country where incident occurred Unspecified location Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland	Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee	Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon
Country or territory outside the United States or Canada (please specify)

4. Year incident occurred

Year incident occurred

5. Age of patient at time of incident

Age of patient at time of incident

6. Sex of patient

Sex of patient M

7. In what size community did the incident occur? (Please give your best estimate.)

In what size community did the incident occur? (Please give your best estimate.) Very large city (greater than 1,000,000 population) Large city (500,000 – 1,000,000 population) Small to mid-sized city (100,000 – 500,000 population)	Very small city (50,000 - 100,000 population) Small town or rural setting
(OPTIONAL) Name of city or community

8. Who is making this report?

Who is making this report? Patient Relative Friend	Healthcare professional Other (please specify below)
(OPTIONAL) If relative or "other," what is your relation to the patient?

9. If you are reporting an incident that affects you or a loved one as a patient, but you (or the patient) are also a practicing or retired healthcare professional, please specify your occupation.

If you are reporting an incident that affects you or a loved one as a patient, but you (or the patient) are also a practicing or retired healthcare professional, please specify your occupation. Physician Registered nurse Allied health professional	Healthcare administrator Other
Additional comments

GENERAL MEDICAL INFORMATION

10. For what condition was the patient seeking treatment when the adverse event occurred?

For what condition was the patient seeking treatment when the adverse event occurred?

11. (OPTIONAL) What if any chronic or underlying disease did the patient have at the time of the incident? (Examples: cancer, heart disease, diabetes, asthma or lung disease)

(OPTIONAL) What if any chronic or underlying disease did the patient have at the time of the incident? (Examples: cancer, heart disease, diabetes, asthma or lung disease)

12. Please list the procedure, treatment or surgery associated with the original adverse event.

Please list the procedure, treatment or surgery associated with the original adverse event.

TYPE OF EVENT

The following sections include questions about different types of adverse events. Several but probably not all sections may be relevant to your event. Please click through the survey and check as many boxes as apply under those questions that apply to your case.

Narrative comment is always welcome; every question has a comment box for further explanation if you should so desire. If you would like to leave narrative only, please scroll through to the narrative box at the end of the survey.

PLEASE NOTE: Any events that are criminal in nature, including abductions, assaults, or homicides are NOT to be reported on this form and should be reported to your local police department.

SURGICAL OR PROCEDURE-RELATED ERRORS OR COMPLICATIONS

13. Surgical or procedure-related errors or complications (Check all that apply)

Surgical or procedure-related errors or complications (Check all that apply) Blood loss from surgery or other procedure

Unintentional cut, puncture, or tear of a blood vessel, organ, nerve, or other body part

Foreign object left in patient after surgery or procedure

Anesthesia awareness (patient was awake or felt pain while under anesthesia)

Other anesthesia-related complication

Burns from a fire on the patient in the operating room (surgical fire)

Burn during surgery - not associated with a fire

Wrong-site surgery or procedure

Procedure or surgery performed on wrong patient

Wrong procedure

Post-operative infection

Other post-operative complication or problem during recovery

Nerve damage from positioning the patient during surgery (positioning injury)

Other complications/Additional comments

HEALTHCARE-ASSOCIATED INFECTION OR PNEUMONIA

14. Did the patient get an infection or pneumonia while under medical treatment or in a healthcare-related facility? If not, please skip to Question 17.

Did the patient get an infection or pneumonia while under medical treatment or in a healthcare-related facility? If not, please skip to Question 17. Yes (Please answer Questions 14, 15, and 16)

No (Please skip to Question 17)

15. Healthcare-associated infection or pneumonia (Check all that apply)

Healthcare-associated infection or pneumonia (Check all that apply) Infection at site of surgery Other infection following surgery Sepsis or bloodstream infection Infected pressure sore or ulcer (bed sore or decubitus ulcer) Diarrhea caused by intestinal infection (for example, c diff) Necrotizing fasciitis (flesh-eating bacteria) associated with surgery or treatment	Urinary tract infection associated with a urinary catheter Infection at site of IV Infection at site of central line, PICC line or port Pneumonia that developed while on a ventilator (breathing machine) Aspiration pneumonia (pneumonia caused by inhaling food or other substance) Other pneumonia
Other Infection or Pneumonia/Additional comments

16. If patient got an infection, please name the bacteria, virus, or fungus involved, if known. (Check all that apply)

If patient got an infection, please name the bacteria, virus, or fungus involved, if known. (Check all that apply) Don't know MRSA (antibiotic-resistant Staph aureus) MRSE (antibiotic-resistant Staph epidermidis) VRSA (Vancomycin-resistant staph) Staphylococcus infection (Staph) not specified as antibiotic-resistant Streptococcus (Strep) C diff (Clostridium difficile)	VRE (Vancomycin-resistant Enterococcus) E. coli Enterococcus not specified as antibiotic-resistant Acinetobacter baumannii Pseudomonas aeruginosa Klebsiella Legionella	Enterobacter Unspecified gram negative bacteria Serratia marescens Aspergillus or other fungus Candida or other yeast infection Other pathogen not listed above
Comments

17. If patient had a bloodstream infection or sepsis, please specify the origin of the infection, if known (Check all that apply)

If patient had a bloodstream infection or sepsis, please specify the origin of the infection, if known (Check all that apply) Don’t know Nick or perforation during surgery or other invasive procedure Infection at site of surgery Pressure sore or ulcer (bed sore or decubitus ulcer) IV	Central line, PICC line or port Urinary catheter Back, hip, knee or other joint surgery with implanted hardware Back, hip, knee or other joint surgery without implanted hardware Perforated ulcer or damage to bowel from medication
Other origin/Additional information

PROBLEMS WITH MEDICATIONS

18. Adverse medication events (Check all that apply)

Adverse medication events (Check all that apply) Overdose

Overdose or underdose related to patient-controlled anesthesia (PCA pump)

Medication prescribed to which patient was known to be allergic

Medication prescribed for incorrect purpose or at incorrect dosage

Drug interaction (medications that should not be used together were given)

Patient was prescribed or given medication that should not be given to a person with the patient's condition

Patient was given medication that had not been prescribed for him/her or was intended for another patient

Pharmacist filled prescription incorrectly

Medication was improperly administered (examples: IV medication injected into muscle; medication not given on time; missed dose)

Epidural or spinal anesthesia error

Patient had an adverse reaction even though the medication was prescribed according to manufacturer’s directions or accepted off-label use

Patient was not given medication that he/she needed to have

Patient was not given adequate medication to control pain

Patient was prescribed a generic medication that did not have the same effect as brand-name medication

Healthcare providers did not recognize that the patient was suffering from medication side effects

Patient became addicted to pain medication

Other medication events/Additional comments

19. If patient experienced an adverse medication event, please give the medication(s) involved and briefly describe what happened to the patient.

If patient experienced an adverse medication event, please give the medication(s) involved and briefly describe what happened to the patient. Blood thinners (Heparin, Warfarin, Coumadin, Plavix, etc.)

Narcotic pain medications (morphine, Dilaudid, Oxycontin, etc.)

Insulin

Other diabetes medications

NSAID pain medications (Toradol, Vioxx, Motrin, Advil, etc.)

Sleep medications (Ambien, Halcion, etc.)

Benzodiazepines (Valium, Diazepam, Ativan, etc.)

Antibiotics

Chemotherapy medications

Psychiatric medications including antidepressants, anticonvulsants, ADD drugs

Acetaminophen (e.g., Tylenol and compounds containing Tylenol)

Drugs used in anesthesia

Heart medications (for example, digoxin)

Steroid medications

Diuretics (Lasix, Diuril, etc.)

Please specify the medications and briefly describe what happened to the patient.

20. Did the patient have a complication associated with childbirth? If not, please skip to Question 24.

Did the patient have a complication associated with childbirth? If not, please skip to Question 24. Yes (Please answer Questions 20, 21, 22 and 23)

No (Please skip to Question 24)

COMPLICATIONS OF CHILDBIRTH OR COMPLICATIONS IN A NEWBORN BABY

21. Complications in infant at birth (Check all that apply)

Complications in infant at birth (Check all that apply) Death of baby at birth or baby born dead Brain damage in baby at birth Shoulder injury to baby during birth (shoulder dystocia or Erb’s Palsy) Complication resulting from inadequate monitoring of baby’s heart rate Delay in performing Caesarean section Respiratory distress or pneumonia in baby	Baby was dropped Infection in newborn baby Complication resulting from untreated jaundice in a newborn baby (kernicterus) Complication from other untreated condition in newborn Complication related to circumcision
Other complications/Additional comments

22. Childbirth-related complications in a mother (Check all that apply)

Childbirth-related complications in a mother (Check all that apply) Death of the mother in childbirth or associated with childbirth Complication associated with labor-inducing drugs Complication associated with epidural or other regional anesthesia Complication of episiotomy Injury to mother associated with forceps delivery Severe bleeding during labor or delivery, or following birth	Retained placenta Deep vein thrombosis or other blood clots requiring treatment Infection in mother following childbirth or Caesarean section Other complication of Caesarean section Postpartum depression or psychosis (depression or severe mental changes following birth)
Other complications/Additional comments

23. If the patient experienced a childbirth-related complication, please describe the conditions of the birth and interventions used (Check all that apply)

If the patient experienced a childbirth-related complication, please describe the conditions of the birth and interventions used (Check all that apply) Unmedicated childbirth with natural-onset labor

VBAC (vaginal birth after Caesarean)

Twins or other multiple birth

Other high-risk pregnancy

Labor induced by Pitocin drip or other drugs

Labor induced by artificial rupture of membranes (i.e., breaking the bag of waters)

Epidural or spinal anesthesia

General anesthesia

Vacuum extractor

Forceps

Episiotomy

Repair of a tear

Scheduled Caesarean section

Unplanned or emergency Caesarean section

Home birth

Other complication/Additional comments

OTHER COMPLICATIONS OF MEDICAL TREATMENT

24. Other complications or errors in diagnosis or treatment (Check all that apply)

Other complications or errors in diagnosis or treatment (Check all that apply) Misdiagnosis Laboratory or pathology error Delay in diagnosis or treatment Proper tests were not ordered Test results were lost, misplaced, or disregarded Delay in providing treatment to a patient who was getting worse (failure to rescue) Pulmonary embolism, blood clot or DVT (deep vein thrombosis)	Pressure ulcer or bedsore Complications from not controlling blood sugar levels Blood transfusion error or reaction (such as blood incompatibility) Problem with IV or central line (excluding infections listed above) Ventilator (breathing device) injury or death (excluding infections listed above) Medical equipment problem
Other complications or errors/Additional comments

ACCIDENTS OR FAILURE TO PROPERLY SUPERVISE THE PATIENT

25. Accidents or failure to supervise the patient (Check all that apply)

Accidents or failure to supervise the patient (Check all that apply) Patient fall or injury while walking or trying to walk Patient entrapment in bed or fall while trying to climb over bedrails Patient death or injury while in restraints Burn not associated with surgery	Patient slipped away from a facility without a planned discharge Suicide while a patient in a medical facility Unexpected death or suicide while under outpatient medical or psychiatric treatment
Other accidents/Additional comments

PATIENT OUTCOME FROM EVENT

26. PATIENT OUTCOME FROM EVENT (Check all that apply)
(Please briefly provide details in the box at end of the question)

PATIENT OUTCOME FROM EVENT (Check all that apply) (Please briefly provide details in the box at end of the question) Death (other than suicide) Suicide Brain damage Chronic pain Need for additional surgery or treatment Loss of bowel or bladder control Disfigurement (Change in appearance) Short Term Loss of function (less than 3 months)	Long-Term Loss of function (more than 3 months) Permanent loss of function or disability Post-traumatic stress or emotional trauma Financial loss No injury – near miss No serious injury Not sure yet (for recent events)
Other outcome/Additional information

27. What was the effect of the event on the patient's family and significant others? (Check all that apply)

What was the effect of the event on the patient's family and significant others? (Check all that apply) Little or no effect Emotional trauma Guilt	Financial loss Loss of employment Loss of lifestyle	Loss of home Stress of caregiving Divorce
Other effect/Additional comments

28. If the patient experienced financial loss or had to utilize additional resources, please categorize the type of expenditure.

If the patient experienced financial loss or had to utilize additional resources, please categorize the type of expenditure. Personal expense (out-of-pocket costs for medications or supplies) Personal expense (personal loans, use of savings) Personal expense (cost of home care) Employer benefits (short-term disability) Employer benefits (long-term disability)	Employer benefits (use of accrued sick or vacation time) Medicaid coverage Food stamps Unemployment benefits SSI disability income	Catastrophic illness funds Bankruptcy filed due to medical costs Community/state funding (please list below) Other medical expense sources (please list below)
List community/state funding or other medical expense sources

GENERAL INFORMATION ABOUT THE EVENT

29. WHERE DID THE EVENT HAPPEN?

WHERE DID THE EVENT HAPPEN? General hospital Teaching hospital Psychiatric or behavioral health facility Emergency department Nursing home	Assisted living facility Rehab unit or long-term acute care facility Dialysis unit Freestanding birthing center Outpatient surgery center	Other outpatient clinic or health center Home Clinical laboratory (e.g., for lab or pathology error) Doctor’s office or other healthcare provider’s office Pharmacy or drugstore
Other location/Additional comments

30. PERSONNEL INVOLVED (Check all that apply)

PERSONNEL INVOLVED (Check all that apply) Primary care physician Surgeon Board-certified obstetrician (for birth) Other physician (please cite specialty below, if known) Resident physician Pathologist Nurse practitioner Other nurse	Hospital Administration Lay midwife Pharmacist Chiropractor Other professional health worker (Examples: radiation technician, respiratory therapist) Nurse tech, medical assistant, or other unlicensed assistive personnel Emergency Medical Responders (EMS) Social worker
Other personnel/Additional comments

31. CONTRIBUTING FACTORS TO THE ADVERSE EVENT (Choose as many as apply)

Other contributing factors/Comments

HEALTHCARE PROVIDER/FACILITY RESPONSE TO THE EVENT

32. HOW DID YOU LEARN WHAT HAD HAPPENED?

HOW DID YOU LEARN WHAT HAD HAPPENED? I am still trying to find out what happened Institution or healthcare provider disclosed the error From the patient (or you are the patient) Staff member warned you privately that something had gone wrong From a witness (not healthcare provider or staff) From a doctor or staff member at another hospital or office	Reading the medical record Through a complaint process Through my own research or investigation Witnessed the event personally Autopsy
Other means/Additional comments

33. HOW DID THE FACILITY OR HEALTHCARE PROVIDER RESPOND? (Check all that apply)

HOW DID THE FACILITY OR HEALTHCARE PROVIDER RESPOND? (Check all that apply) Open, concerned, and transparent

Apologized and took responsibility for incident

Offered to compensate or otherwise make amends to patient/family

Event was investigated and patient/family were kept informed

Patient/family were interviewed as part of investigation of the event

Patient/family were included as part of the investigating team

Secretive or unwilling to include patient or family in evaluating the situation

No response after request to investigate

Denied responsibility

Told patient/family that care was "appropriate" when it did not appear to be

Individual providers who were involved were not available to discuss the event with patient/family

Tried to prevent patient/family from getting critical information

Removed information or altered medical records

Other response/Comments

34. Do you feel that the patient or patient's family members later had a difficult time getting medical care because of the adverse event?

Do you feel that the patient or patient's family members later had a difficult time getting medical care because of the adverse event? Yes	No
Comments

LEGAL AND REGULATORY CONSEQUENCES OF THE ADVERSE EVENT (OPTIONAL)

35. Did the patient or family consider suing over the adverse event?

Did the patient or family consider suing over the adverse event? Yes

36. Why did the patient or family consider suing, or why not? (Check all that apply)

Why did the patient or family consider suing, or why not? (Check all that apply) Patient/family did not want to sue because provider or facility seemed remorseful and open

Patient/family did not feel a need to sue because provider or facility provided compensation without a lawsuit

The event was not serious enough for a lawsuit

Patient/family felt there was no point in suing because a lawsuit would not change the past

Patient/family did not want to be subjected to the ordeal of litigation

Patient/family were concerned about the expense of litigation

Patient/family wanted to hold the responsible parties accountable

Patient/family wanted to find out what had happened

Patient/family had to sue because of the financial losses they had suffered

Patient/family were angry at the way they had been treated by the facility or provider

Patient/family wanted to make sure that the same thing did not happen to somebody else

Other reason/Comments

37. Did the patient or family consult a lawyer concerning the adverse event?

Did the patient or family consult a lawyer concerning the adverse event? Yes (Please answer Questions 35-39)

No (Please skip to Question 40)

38. If the patient or family consulted a lawyer or tried to pursue legal action, what was the outcome? (Check all that apply)

If the patient or family consulted a lawyer or tried to pursue legal action, what was the outcome? (Check all that apply) Family did not have the legal standing to sue under state/provincial law

After consulting a lawyer, patient/family decided not to file suit

Patient/family did not sue because no suitable lawyer wanted to take the case

Patient or family acted as their own attorney

Lawyer told patient/family that caps on medical malpractice payments made the case too expensive to bring

Lawyer asked family to pay legal expenses up front

Lawyer took the case on contingency basis

Lawyer took the case, but dropped it before filing a lawsuit

Lawsuit was dismissed

Case settled out of court without lawsuit being filed

Case settled out of court after filing lawsuit

Case settled for attorneys' expenses only

Case went to trial with verdict in favor of plaintiffs

Case went to trial with verdict in favor of defendants

Verdict was appealed

Case was settled according to pre-arranged agreement for less than the jury's verdict

Insurance company, Medicare or Medicaid placed a lien on settlement or jury award

Lawsuit is still ongoing

Other outcome/Additional comments

39. If the patient or family settled a case, did they sign a confidentiality clause agreeing not to discuss any of the following? (Check all that apply)

If the patient or family settled a case, did they sign a confidentiality clause agreeing not to discuss any of the following? (Check all that apply) The amount of the settlement

The existence of the settlement

The details of the adverse event

The names of the parties to the lawsuit

The existence of the confidentiality agreement

Other agreements /Additional comments

40. If the patient or family signed a confidentiality agreement, what was the reason for signing?

If the patient or family signed a confidentiality agreement, what was the reason for signing? Patient/family felt compelled to sign because they were told the defense would not settle without a confidentiality agreement

Patient/family signed the agreement voluntarily because they wanted to keep the details of the settlement confidential

Other/Additional comments

41. If the patient or family pursued legal action (with or without success), how long did the legal process last?

If the patient or family pursued legal action (with or without success), how long did the legal process last?

42. If the patient or family received a legal settlement or other financial compensation, how much did they actually receive after medical liens, subrogation of medical expenses, and legal expenses?

If the patient or family received a legal settlement or other financial compensation, how much did they actually receive after medical liens, subrogation of medical expenses, and legal expenses? The lawsuit cost us more than we received 0 Less than $30,000 $31,000-$100,000	$101,000-$250,000 $251,000-$500,000 $501,000-$1,000,000 More than $1 million
Other/Additional comments

REGULATORY FOLLOW-UP TO THE ADVERSE EVENT

Please note that the scope of problems in medical care can only be assessed if problems are reported to the appropriate authorities. Links to regulatory and accrediting agencies can be found at www.empoweredpatientcoalition.org/report-a-medical-event. If you have not yet reported your incident, we urge you to do so.

43. To what agencies and institutions, if any, did the patient, family, or other individuals report the adverse event?

To what agencies and institutions, if any, did the patient, family, or other individuals report the adverse event? Not reported

Reported to administration of facility or office where incident occurred

Reported to state health department

Reported to state medical or nursing board or other licensing board

Reported to the Joint Commission

Reported to Accreditation Council for Graduate Medical Education (ACGME)

Reported to Medicare/Medicaid

Filed HIPAA complaint for privacy violation (FIPPA in Canada)

Reported to Food and Drug Administration

Reported to Institute for Safe Medication Practices (ISMP) or ConsumerMedSafety

Insurance company

Ombudsman or Patient Relations

Canadian Health Authority

Canada - Provincial Minister of Health

Other agencies/Additional comments

44. Were you satisfied with the response of the institutions or agencies to which you reported?

Were you satisfied with the response of the institutions or agencies to which you reported? Yes

Please briefly describe the response to your reports

OPTIONAL NARRATIVE OR COMMENT

45. NARRATIVE (Please give a brief description of the incident and any additional comments or suggestions you have for how the incident might have been prevented.)

NARRATIVE (Please give a brief description of the incident and any additional comments or suggestions you have for how the incident might have been prevented.)

46. Consumers Union
This survey was created in collaboration with the Consumers Union Safe Patient Project (www.safepatientproject.org), which welcomes input from those who would like to share their stories of medical harm. The Consumers Union Safe Patient Project seeks to eliminate medical harm through public disclosure about patient safety events such as hospital-acquired infections and medical errors, as well as information about health care providers and the safety of prescription drugs.

May we share your story with Consumers Union?

Consumers Union This survey was created in collaboration with the Consumers Union Safe Patient Project (www.safepatientproject.org), which welcomes input from those who would like to share their stories of medical harm. The Consumers Union Safe Patient Project seeks to eliminate medical harm through public disclosure about patient safety events such as hospital-acquired infections and medical errors, as well as information about health care providers and the safety of prescription drugs. May we share your story with Consumers Union? Yes

47. Thank you for completing our survey. Please tell us if you have suggestions for improving our reporting process. For more information or to see survey results, please visit www.empoweredpatientcoalition.org.

Thank you for completing our survey. Please tell us if you have suggestions for improving our reporting process. For more information or to see survey results, please visit www.empoweredpatientcoalition.org.

	Did not occur or not applicable	Occurred, but was not a serious problem	Serious problem in patient's care	Major factor affecting patient outcome
Patient was not given the information needed to make an informed decision	*CONTRIBUTING FACTORS TO THE ADVERSE EVENT (Choose as many as apply) Patient was not given the information needed to make an informed decision Did not occur or not applicable	Patient was not given the information needed to make an informed decision Occurred, but was not a serious problem	Patient was not given the information needed to make an informed decision Serious problem in patient's care	Patient was not given the information needed to make an informed decision Major factor affecting patient outcome
Healthcare personnel did not listen to patient or family	Healthcare personnel did not listen to patient or family Did not occur or not applicable	Healthcare personnel did not listen to patient or family Occurred, but was not a serious problem	Healthcare personnel did not listen to patient or family Serious problem in patient's care	Healthcare personnel did not listen to patient or family Major factor affecting patient outcome
Patient was not properly monitored	Patient was not properly monitored Did not occur or not applicable	Patient was not properly monitored Occurred, but was not a serious problem	Patient was not properly monitored Serious problem in patient's care	Patient was not properly monitored Major factor affecting patient outcome
Nurse did not respond quickly to the call button	Nurse did not respond quickly to the call button Did not occur or not applicable	Nurse did not respond quickly to the call button Occurred, but was not a serious problem	Nurse did not respond quickly to the call button Serious problem in patient's care	Nurse did not respond quickly to the call button Major factor affecting patient outcome
Doctor was slow to arrive	Doctor was slow to arrive Did not occur or not applicable	Doctor was slow to arrive Occurred, but was not a serious problem	Doctor was slow to arrive Serious problem in patient's care	Doctor was slow to arrive Major factor affecting patient outcome
Healthcare personnel did not communicate well with each other	Healthcare personnel did not communicate well with each other Did not occur or not applicable	Healthcare personnel did not communicate well with each other Occurred, but was not a serious problem	Healthcare personnel did not communicate well with each other Serious problem in patient's care	Healthcare personnel did not communicate well with each other Major factor affecting patient outcome
Healthcare personnel seemed untrained or lacking in necessary knowledge	Healthcare personnel seemed untrained or lacking in necessary knowledge Did not occur or not applicable	Healthcare personnel seemed untrained or lacking in necessary knowledge Occurred, but was not a serious problem	Healthcare personnel seemed untrained or lacking in necessary knowledge Serious problem in patient's care	Healthcare personnel seemed untrained or lacking in necessary knowledge Major factor affecting patient outcome
Healthcare personnel seemed over-confident	Healthcare personnel seemed over-confident Did not occur or not applicable	Healthcare personnel seemed over-confident Occurred, but was not a serious problem	Healthcare personnel seemed over-confident Serious problem in patient's care	Healthcare personnel seemed over-confident Major factor affecting patient outcome
Healthcare personnel seemed overtired or fatigued	Healthcare personnel seemed overtired or fatigued Did not occur or not applicable	Healthcare personnel seemed overtired or fatigued Occurred, but was not a serious problem	Healthcare personnel seemed overtired or fatigued Serious problem in patient's care	Healthcare personnel seemed overtired or fatigued Major factor affecting patient outcome
Healthcare personnel seemed overworked, rushed, or behind schedule	Healthcare personnel seemed overworked, rushed, or behind schedule Did not occur or not applicable	Healthcare personnel seemed overworked, rushed, or behind schedule Occurred, but was not a serious problem	Healthcare personnel seemed overworked, rushed, or behind schedule Serious problem in patient's care	Healthcare personnel seemed overworked, rushed, or behind schedule Major factor affecting patient outcome
Healthcare personnel did not communicate important information to patient	Healthcare personnel did not communicate important information to patient Did not occur or not applicable	Healthcare personnel did not communicate important information to patient Occurred, but was not a serious problem	Healthcare personnel did not communicate important information to patient Serious problem in patient's care	Healthcare personnel did not communicate important information to patient Major factor affecting patient outcome
Healthcare personnel did not seem familiar with the patient’s case	Healthcare personnel did not seem familiar with the patient’s case Did not occur or not applicable	Healthcare personnel did not seem familiar with the patient’s case Occurred, but was not a serious problem	Healthcare personnel did not seem familiar with the patient’s case Serious problem in patient's care	Healthcare personnel did not seem familiar with the patient’s case Major factor affecting patient outcome
Healthcare personnel did not seem concerned about the patient	Healthcare personnel did not seem concerned about the patient Did not occur or not applicable	Healthcare personnel did not seem concerned about the patient Occurred, but was not a serious problem	Healthcare personnel did not seem concerned about the patient Serious problem in patient's care	Healthcare personnel did not seem concerned about the patient Major factor affecting patient outcome
Patient’s room not cleaned properly, environment not sanitary	Patient’s room not cleaned properly, environment not sanitary Did not occur or not applicable	Patient’s room not cleaned properly, environment not sanitary Occurred, but was not a serious problem	Patient’s room not cleaned properly, environment not sanitary Serious problem in patient's care	Patient’s room not cleaned properly, environment not sanitary Major factor affecting patient outcome
Healthcare personnel did not follow sanitary procedure	Healthcare personnel did not follow sanitary procedure Did not occur or not applicable	Healthcare personnel did not follow sanitary procedure Occurred, but was not a serious problem	Healthcare personnel did not follow sanitary procedure Serious problem in patient's care	Healthcare personnel did not follow sanitary procedure Major factor affecting patient outcome
Medical procedures or treatments were not performed carefully	Medical procedures or treatments were not performed carefully Did not occur or not applicable	Medical procedures or treatments were not performed carefully Occurred, but was not a serious problem	Medical procedures or treatments were not performed carefully Serious problem in patient's care	Medical procedures or treatments were not performed carefully Major factor affecting patient outcome
Premature discharge	Premature discharge Did not occur or not applicable	Premature discharge Occurred, but was not a serious problem	Premature discharge Serious problem in patient's care	Premature discharge Major factor affecting patient outcome
Lack of follow-up after discharge	Lack of follow-up after discharge Did not occur or not applicable	Lack of follow-up after discharge Occurred, but was not a serious problem	Lack of follow-up after discharge Serious problem in patient's care	Lack of follow-up after discharge Major factor affecting patient outcome
Other (please describe below)	Other (please describe below) Did not occur or not applicable	Other (please describe below) Occurred, but was not a serious problem	Other (please describe below) Serious problem in patient's care	Other (please describe below) Major factor affecting patient outcome