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WELCOME

Most reporting systems for adverse medical events are concerned with collecting information for use by health care providers. The Empowered Patient Coalition survey is designed to answer questions that are important to patients. What procedures are associated with harm? What are the common factors patients see as leading to harm, and how do health care providers respond? This survey is a way for patients to report their experiences as they have lived it, and to know that their report will be counted and added to the voices of other people.

The survey is divided into sections covering various categories of medical adverse events. Answers in the categories can be as brief or as lengthy as you wish. Boxes simply can be checked but we encourage you to use the narrative boxes 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, we would appreciate it if you would fill out a separate survey for each event. Adverse events do not have to be recent - events can be reported from any time period.

Unless you explicitly give it to us, we do not collect your computer IP address, 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 with subjective information, we make our findings available at www.EmpoweredPatientCoalition.org.

Please click below to begin the survey and thank you for sharing your experiences.

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* 1. Personal Information

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* 2. May we contact you regarding your survey? (Please be sure to provide contact information)

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* 3. State, province, or country where incident occurred

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* 4. Year incident occurred

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* 5. Age of patient at time of incident

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* 6. Sex of patient

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* 7. In what size community did the incident occur?

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* 8. What type of medical insurance did the patient have at the time of the event?

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* 9. Who is making this report?

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* 10. 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.

GENERAL MEDICAL INFORMATION

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

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

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* 13. 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 categories will be relevant to your event. Please click through the survey and check as many boxes as apply under those questions that pertain to your event.

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

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

HEALTHCARE-ASSOCIATED INFECTION OR PNEUMONIA

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* 15. Did the patient get an infection or pneumonia while under medical treatment or in a healthcare-related facility? If not, please skip to Question 19.

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

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

PROBLEMS WITH MEDICATIONS

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

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* 19. Adverse medication events (Check all that apply)

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

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* 21. Did the patient have a complication associated with childbirth? If not, please skip to Question 25.

COMPLICATIONS OF CHILDBIRTH OR COMPLICATIONS IN A NEWBORN

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

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

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

OTHER COMPLICATIONS OF MEDICAL TREATMENT

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

ACCIDENTS OR FAILURE TO PROPERLY SUPERVISE THE PATIENT

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* 26. Accidents or failure to properly supervise the patient (Check all that apply)

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

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

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* 29. If the patient experienced financial loss or had to utilize additional resources, please categorize the type of expenditure. (Check all that apply)

GENERAL INFORMATION ABOUT THE EVENT

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* 30. WHERE DID THE EVENT HAPPEN?

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* 31. PERSONNEL INVOLVED (Check all that apply)

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

  Did not occur or not applicable Occurred, but 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
Healthcare personnel did not listen to patient or family
Patient was not properly monitored
Nurse did not respond quickly to the call button
Doctor was slow to arrive
Healthcare personnel did not communicate well with each other
Healthcare personnel seemed untrained or lacking in knowledge
Healthcare personnel seemed over-confident
Healthcare personnel seemed overtired or fatigued
Healthcare personnel seemed overworked, rushed, or behind schedule
Healthcare personnel did not seem familiar with the patient's case
Healthcare personnel did not communicate important information to patient
Healthcare personnel did not seem concerned about the patient
Patient's room not cleaned properly, environment not sanitary
Healthcare personnel did not follow sanitary procedure
Medical procedures or treatments were not performed carefully
Premature discharge
Lack of follow-up after discharge
Other (please describe below)
HEALTHCARE PROVIDER/FACILITY RESPONSE TO THE EVENT

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* 33. HOW DID YOU LEARN WHAT HAD HAPPENED? (Check all that apply)

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

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

LEGAL AND REGULATORY CONSEQUENCES OF THE ADVERSE EVENT (OPTIONAL)

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

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* 37. If the patient or family DID NOT want to sue, what were the reasons? (Check all that apply)

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* 38. If the patient or family DID want to sue, what were the reasons? (Check all that apply)

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

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* 40. If the patient or family consulted a lawyer, what was the outcome of the interaction with the attorney? (Check all that apply)

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* 41. If the patient or family pursued legal action, what was the outcome of the case? (Check all that apply)

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* 42. 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)

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

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

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

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 event, we urge you to do so, even if the event is not recent.

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

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* 47. Were you satisfied with the response of the institutions or agencies to which you reported the adverse event?

OPTIONAL NARRATIVE OR COMMENT

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* 48. 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.)

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* 49. CONSUMERS UNION
This survey was created in a joint collaboration between The Empowered Patient Coalition and 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 of patient safety events such as hospital-acquired infections and medical errors, as well as information about health care providers, the safety of prescription drugs and problems with medical devices.

May we share your story with Consumers Union?

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* 50. Are you interested in sharing your story with members of the media reporting on health care issues? If so, please be sure that you have entered your contact information above or enter it in the box below.

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* 51. Thank you for completing our survey. Please tell us if you have suggestions for improving our reporting process and please alert others who may have experienced adverse events to complete the survey. For more information or to see survey results, please visit www.EmpoweredPatientCoalition.org.

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