QUAPI Incident

Question Title

* 1. Type of Event

Shoulder Dystocia

Postpartum Hemorrhage

Hypertensive Emergency and or Eclampsia

3rd or 4th Degree Tear

Low Apgars < 7 at 5 minutes

Environmental Event - Fall, injury, etc.

Transfer of Care Event (ONLY those for QUAPI Review)

All NICU admissions

Manual Removal of placenta at Birthcenter

Abnormal newborn metabolic, CCHD, or hearing screen without appropriate follow-up or referral, undiagnosed or untreated hyperbilirubinemia

Lab Error Event

Documentation Error

Invasive Procedure Event

Potential Criminal Event

Product or Device Event - Malfunction of or non-working clinical equipment, supply not available

Client Protection Event - Concern for adverse health outcome

Medication Error

Client Complaint

Other

Question Title

* 2. Please List the Client involved in the incident

Question Title

* 3. Date/Time incident occurred

Date / Time

Date

Time

AM/PM

Question Title

* 4. What is the location where this event occurred

Fort Worth Birthing & Wellness Center

Midwife+Co Fort Worth

Midwife+Co Dallas

Texas Health Harris Methodist Fort Worth

Baylor University Medical Center in Dallas

Texas Health Resources in Mansfield

Client's Home

Other

QUAPI Incident

Question Title

* 1. Type of Event

Question Title

* 2. Please List the Client involved in the incident

Question Title

* 3. Date/Time incident occurred

Question Title

* 4. What is the location where this event occurred

Question Title

* 5. Please describe the incident in detail.