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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.

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* 1. Personal Information (OPTIONAL)

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* 2. May we contact you regarding your survey?

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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? (Please give your best estimate.)

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* 8. Who is making this report?

GENERAL MEDICAL INFORMATION

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

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* 10. (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)

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* 11. 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

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

HEALTHCARE-ASSOCIATED INFECTION, PRESSURE SORE, OR PNEUMONIA

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* 13. Did the patient get an infection, pressure sore, or pneumonia while under medical treatment or in a healthcare-related facility? If not, please skip to Question 16.

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* 14. Healthcare-associated infection, pressure sore, or pneumonia (Check all that apply)

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* 15. If patient got an infection, please name the bacteria or other infectious agents involved, if known.

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

PROBLEMS WITH MEDICATIONS

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

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

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* 19. Did the patient have a complication associated with childbirth? If not, please skip to Question 23.

COMPLICATIONS OF CHILDBIRTH OR COMPLICATIONS IN A NEWBORN BABY

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

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

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

OTHER COMPLICATIONS OF MEDICAL TREATMENT

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* 23. Other complications of medical treatment (Check all that apply)

ACCIDENTS OR FAILURE TO PROPERLY SUPERVISE THE PATIENT

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

PATIENT OUTCOME FROM EVENT

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

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* 26. What was the effect of the event on the patient's family and significant others?

GENERAL INFORMATION ABOUT THE EVENT

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* 27. WHERE DID THE EVENT HAPPEN?

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* 28. PERSONNEL INVOLVED (Check all that apply)

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

  Did not occur 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
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 necessary knowledge
Healthcare personnel seemed over-confident
Healthcare personnel seemed overtired or fatigued
Healthcare personnel seemed overworked, rushed, or behind schedule
Healthcare personnel did not communicate important information to patient
Healthcare personnel did not seem familiar with the patient’s case
Healthcare personnel did not seem concerned about the patient or family
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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* 30. HOW DID YOU LEARN WHAT HAD HAPPENED?

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* 31. HOW DID THE FACILITY OR HEALTHCARE PROVIDER RESPOND?

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* 32. WAS THE PATIENT OR FAMILY INTERVIEWED ABOUT THE EVENT?

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* 33. Who was the interviewer?

LEGAL AND REGULATORY CONSEQUENCES OF THE ADVERSE EVENT (OPTIONAL)

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

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

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

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

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

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

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

OPTIONAL NARRATIVE OR COMMENT

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* 42. 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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* 43. 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.

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