Who was affected by the event?
*
Faculty Patient Staff Student Visitor Unsafe conditions or improvements
If this event involves a PATIENT, do NOT select this category.
Date of admission or ambulatory encounter
Today M-D-Y
Patient Identifier (chart number)
*
Date of birth (mm/dd/yyyy)
*
Today M-D-Y
Female Male Nonbinary Gender Nonconforming Gender Fluid Transgender Agender Other Not Stated
Adverse reaction Anesthesia event Swallowed or aspirated object Behavioral event Bleeding Care coordination/communication Complication of Endodontics Complication of surgery or anesthesia Complication of care (unanticipated, non surgical) Equipment/devices Event relating to surgery or invasive procedure Fall Hard tissue damage Healthcare-associated infection (HAI) HIPAA related event Infection Control Medical emergency Medical records/patient identification Medication related Nerve injury Omission/errors in assessment, diagnosis, monitoring Other/miscellanous Pain Quality of Care Issue Radiology/Imaging test Security issues Skin integrity Soft tissue injury or inflammation Supplies Wrong patient Wrong tooth/side/site
Assault Call to medical response team Exposure to blood or body fluids Exposure to chemicals or drugs Fall (staff or visitor) Inappropriate behavior Injury Other
Cardiac/Circulatory Glucose Management Neurological Complication Respiratory Complication Other
Environmental issues Equipment safety HIPAA related event Infection control Infrastructure failure Medication-related issues Other Security issues
Damage to property Environmental hazard Failed test of standard procedures Inadequate supplies Other (Environmental)
Equipment not working/missing Other (Equipment safety) Preventative maintenance not performed Sterilization
Biological indicator issue Cassette/instrument Documentation
Break in isolation/transmission precautions Break in sterile technique Hand hygiene not performed Improper disposal of contaminated items Non compliance with sharps safety Other (infection control) Personal protective equipment not worn Precautions not ordered or not communicated
Activation of internal or external emergency plan Disruption/interruption of clinical service Disruption/interruption of utility (e.g., power failure) EMTALA violation Fire Hospital on divert status Information system problem Other (infrastructure)
Automated dispensing machine problem CPOE errors for medications Drug diversion/theft Narcotics discrepancy Other (Medication related issues)
Criminal/potentially criminal or illegal activity Lost/stolen property Other (Security issues) Unauthorized presence
Assuming identity of another person or identity theft Impersonating a dentist, dental assistant, or other healthcare provider Other (criminal/potentially criminal or illegal activity)
Break in isolation/transmission precautions Break in sterile technique Other (infection control)
Adverse drug reaction (not a med error/not preventable) Allergic reaction to dental materials Latex/tapes Other
Airway management issues Aspiration Injury related to anesthesia Other (anesthesia) Problems with anesthesia, medical gas, other substance Prolonged recovery time Unplanned use of reversal agents
Difficulty maintaining airway during procedure Other (airway management)
Dental Ocular Peripheral nerve Other
Nitrous Oxide Other (problems with anesthesia or medical gas)
Aspiration of object Near miss swallowed object Swallowed object
bur instrument provisional wire fragment crown orthodontics bracket radiolucent object tooth other
bur instrument provisional wire fragment crown orthodontics bracket radiolucent object tooth other
bur instrument provisional wire fragment crown orthodontics bracket radiolucent object tooth other
Assaulted by patient Assaulted by staff member Assaulted by visitor
Destruction of property Disruptive behavior Inappropriate behavior Other (behavioral) Refusal of therapy Protective stabilization injury/death Self-harm or injury Sexual assault/rape Threat by patient
Assault by patient Assault by staff member Assault by visitor
Excessive bleeding of the donor site after soft-tissue grafting Perforation of arteries during surgical procedure Post-treatment complication: hematoma
Access to care problem Communication inadequate Message handling/response problem Other (Care coordination/Communication) Provider not available Referral/consult problem
Delay in treatment Other (access to care)
Other (communication inadequate) With other providers in ancillary department With other providers in OTHER patient care areas With other providers WITHIN patient care area With outside providers/agencies With patient or family
Delay in scheduling Delay in service Other (Referral/consult problem) Report unavailable/delayed
Endodontic treatment of non-restorable tooth Other complication of Endodontics Perforated tooth Retained object
Cardiac/circulatory event Central nervous system event Damage to patient's dental appliances Death Development of degenerative joint disease after orthognathic surgery Extraction-related Harm to adjacent anatomic structure using instrumentation Hemorrhage requiring unexpected transfusion or return to OR Implant/graft failure Other (Complications of surgery or anesthesia) Unintentional laser burns
Cardiac arrest Myocardial infarction Not Applicable Prolonged hypotension
Stroke or other neurological deficit Unexpected loss of consciousness
Adjacent crown (using instrumentation) Other Tooth
Cardiac complication Damage to patient's dental appliances Glucose management Harm to adjacent anatomic structure using instrumentation Neurological complication Other (Complication of care) Removal of tube or other medical device by patient Respiratory complication Unexpected change in patient status Unexpected death Unexpected injury
Cardiopulmonary arrest Myocardial infarction Other cardiac complication
Hyperglycemia Hypoglycemia
Adjacent crown (using instrumentation) Other Tooth
Confusional state Other (neurological complication) Not Applicable Seizure Stroke Unresponsiveness/loss of consciousness
Other (Respiratory complication) Respiratory distress Not Applicable Respiratory failure
Unplanned transfer Unplanned surgery Unplanned transfer to ICU Unplanned visit to ED post procedure
Other (unexpected injury)
Damage to property Environmental hazard Failed test of standard procedures Inadequate supplies Other (Environmental)
Broken item(s) Disconnected Electrical problem Equipment malfunction Equipment not working/missing Equipment unavailable/ordered, not received Equipment wrong or inadequate Medical device problem Operator training or knowledge problem Other (Equipment/device) Outdated item(s) Preventative maintenance not performed Sterilization Used after product recall
Biological indicator issue Cassette/instrument Documentation
Air embolus Break in sterile technique Burn/fire Event before procedure Foreign body accidentally left in patient (not Endo) Incorrect surgical or invasive procedure Other (Surgery or invasive procedure) Procedure started and not completed Unintended laceration or puncture
Both burn and operating room fire Burn Operating room fire
Antibiotics not given per protocol Consent missing or incomplete Identification missing or incorrect Other (Event before procedure) Preparation inadequate or worng Procedure cancelled or not performed Procedure delayed Procedure not ordered Universal protocol (time-out) not followed
Instrument fragment Needle Other (Foreign body) Whole instrument
Incorrect implant because correct implant not available Other (Incorrect surgical or invasive procedure) Wrong implant by mistake
Bone fracture during extraction Bur injury to adjacent tooth Mandible fracture during third molar extraction Root fractures in the process of placing posts
Antibiotic-associated diarrhea Bloodstream infection (BSI) Colonization by antibiotic-resistant organism (e.g. MRSA, VRE) Other (HAI) Other type of infection (not involving surgical site) attibutable to dental care Pneumonia Sinusitis due to unintended sinus lift Surgical site infection (SSI) Urinary tract infection (UTI)
Not central line-associated
Bone or joint Cardiovascular system Central nervous system ear, nose, throat or mouth Gastrointestinal Lower respiratory tract (other than pneumonia) Other (Other type of infection) Reproductive tract Skin or soft tissue Systemic
Not ventilator-associated
Deep incisional primary Deep incisional secondary Organ/space Stage unknown Superficial incisional primary Superficial incisional secondary
Catheter-associated (CAUTI) Not catheter-associated
Break in isolation/transmission precautions Break in sterile technique Hand hygiene not performed Improper disposal of contaminated items Non compliance with sharps safety Other (Infection control) Personal protective equipment not worn or inappropriately worn Precautions not ordered or not communicated
Activation of internal or external emergency plan Disruption/interruption of clinical services Disruption/interruption of utility (e.g. power failure) EMTALA violation Fire Information system problem Other (Infrastructure)
Cardiac/circulatory Glucose management Neurological complication Respiratory complication other
Antibiotic not given per protocal Fluoride irritation to gastrointestinal lining (gut) Known allergy Known drug interaction Medication-induced candidiasis Monitoring event Other medication event Pain management Prescription/refill delayed Unordered drug given Upper vascular epinephrine injections resulting in rare allergic reaction Wrong dosage form (e.g. sustained vs. immediate release) Wrong dose Wrong drug or substance Wrong duration (of administration or course of therapy) Wrong frequency Wrong patient Wrong preparation or technique Wrong rate (IV) Wrong route Wrong strength/concentration Wrong timing
Documented in record but missed Not documented Unknown/other
Drug-disease Drug-drug Drug-food/nutrient Other (Unknown drug interaction)
Clinical (laboratory value, vital sign) Other monitoring event
Contaminated drug Drug given after recall Expired or deteriorated drug Incorrect patient action (e.g. self-administration error) Medication found in room Other (Other medication event)
Other (Pain management) Overtreatment Undertreatment
Extra dose Missed/omitted dose Overdose Underdose Unknown
Too quickly Too slowly Unknown
Too high Too low Unknown
Too early Too late Unknown
Improper location of injection to parotid gland causing temporary paralysis of facial nerve Mandibular nerve injury Nerve damage during placement of implant Surgical damage to posterior, superior alveolar nerve
lingual nerve injury mental nerve damage/parasthesia inferior alveolar (IA) nerve
Assessment issues Diagnosis issues Monitoring issue or failure to monitor Other (Omission/error in assessment)
Delayed Inaccurate Incomplete Not completed
Delayed diagnosis Diagnosis changed Incorrect diagnosis Missed diagnosis
Abduction of a patient of any age Discharge against urgent medical or dental advice (AMDA) Left before visit completed Left without being seen Lost/stolen belongings Other (Other/miscellaneous) Patient discharged to the wrong person Patient missing/elopment/AWOL Patient or family complaint (report to Patient Advocate) Privacy inadequate
Patient did not sign AMDA form Patient signed AMDA form Unknown/other (specify)
Excessive pain after a dental procedure Inaccurate crown adjustment leading to tooth pain, discomfort, temporomandibular disorder Inadequate anesthesia resulting in pain Root sensitivity after dental surgery
Delivering poor-fitting dentures Esthetic failure, crowns completely different color than patient's teeth Failed crowns due to wrong material selection Impression material lodged in mouth Poor-fitting crowns
Delays preprocedure or postprocedure Discrepancy between ED interpretation of x-ray or EKG and final reading Image unavailable or inadequate Incorrect reading Mislabeled study Not completed Not ordered Ordered, not performed Other (Radiologoy, imaging) Unanticipated radiation exposure
Delay in reporting Other (Delays pre or post procedure) Procedure delayed
Criminal/potentially criminal or illegal activity Lost/stolen property Other (Security issue) Unauthorized presence
Assuming identity of another person or identity theft Impersonating a staff, faculty, student, or resident Other (Criminal/potentially criminal or illegal activity)
Wrong patient near miss Wrong patient Patient identification issues
Is this a radiograph issue?
*
Yes
No
Select all that apply
Wrong side/site local anesthetic Wrong side/site other Wrong tooth
Consent missing/incomplete Incomplete/incorrect chart entry/order entry information Other (Medical records) Patient identification issues Records/chart incomplete Records/chart unavailable
Abrasion/scratch Blister Bruise/ecchymosis Burn (electrical, chemical, thermal) Irritation/reddening Laceration Mucosal ulcer Other (Skin integrity) Pressure ulcer Rash Skin tear Venous stasis ulcer
Improper elevator use resulting in damage to floor of mouth Injuries to soft tissue during debonding in Orthodontics Lip laceration Swelling after osseous surgery Tongue laceration
Inadequate supplies Other (Supplies) Outdated item(s) Sterilization problem Supplies damaged/broken Supplies ordered, not received Supplies ordered; wrong supplies received Used after product recall Wrong supplies used
Today M-D-Y
Now H:M (use the military time format)
Today M-D-Y
Now H:M (use the military time format)
Was health information technology (HIT) implicated in this event?
Yes No Unknown
How did you learn about the event?
Assessment after event
Report by another SDM person
Report by family or visitors
Report by patient
Review of record or chart
Witnessed/involved
Other (please specify)
Select all that apply
1st floor dispensary 2nd floor clinic 2nd floor dispensary 3rd floor (non-ortho) clinic 3rd floor dispensary 4th floor clinic 4th floor dispensary ACTS Clinic Any Stairs Common Area Emergency Clinic Faculty Practice GPR Clinic Healthy Smiles Lab 2nd floor Lab 3rd floor Lab 4th floor Lab DFP Lab Ortho Clinic Main Lab 1st Floor Oral & Maxillofacial Service Oral Surgery Clinic Ortho Dispensary Orthodontics Residency Clinic Other Outside Perimeter Perio Residency Clinic Radiology Simulation Clinic Skyridge Medical Center Sterilization Technique Lab University of Colorado Hospital DFP Dispensary Senior & Special Care Clinic (SSCC)
Clinica Family Health Serv - Lafayette Clinica Family Health Serv- Pecos Clinica Family Health Serv-Thornton Colorado Coalition for the Homeless-Champa Colorado Coalition for the Homeless-Stout Colorado Mental Health Institute at Pueblo Denver Health-Eastside Family Health Center Denver Health-Frederico Pena SW Family Health Center Denver Health-Lowry Family Health Center Denver Health-Montebello Family Health Center Denver Health-Webb Center for Primary Care Denver Health-Westside Family Health Center Fun at the Dentist Homeless Health Center-Colorado Springs Howard Dental Center InnovAge-Aurora InnovAge-Denver InnovAge-Lakewood InnovAge-Thornton Northwest Colorado Health Dental Clinic-Craig Northwest Colorado Health Dental Clinic-South Routt Peak Vista Community Health Centers-Colorado Springs Peak Vista Community Health Centers-Strasburg Pueblo Community Health Center Salud Family Health Center- Ft. Collins West Salud Family Health Center-Commerce City Salud Family Health Center-Estes Park Salud Family Health Center-Frederick Salud Family Health Center-Ft. Collins Blue Spruce Salud Family Health Center-Ft. Lupton Salud Family Health Center-Ft. Morgan Salud Family Health Center-Longmont Salud Family Health Center-Sterling Salud Family Health Center-Trinidad Sheridan Health Service Stride Community Health Centers Pine Tree-Parker Stride Community Health Centers-Arvada Stride Community Health Centers-North Aurora Stride Community Health Centers-Wheat Ridge Sunrise Community Health-Loveland Community Health Center Sunrise Community Health-Sunrise Family Dental Clinic Valley-Wide Health Systems Alamosa Dental Clinic Valley-Wide Health Systems Canyon City Dental Clinic Valley-Wide Health Systems Rocky Ford Dental Clinic Worthmore Clinic
adolescent clinic diagnosis and treatment planning emergency endodontics implants not applicable oral and maxillofacial oral medicine oral pathology oral surgery orthodontics pediatrics periodontics prosthodontics radiology restorative screening Seniors & Special Care Clinic (SSCC) other
Describe the event in your own words
Describe any factors contributing to the event, lessons learned, and/or recommendations to prevent recurrence
Please list any people involved
What type of medication or substance was involved?
Medication Vaccine Nutritional product Medical gas (e.g. oxygen, nitrous oxide) Patient food (not suspected in drug-food interactions) Other substance (specify)
Name of medication prescribed
Buccal Cutaneous, topical application Epidural Gastric Inhalation Intramuscular Intravenous Intrathecal Nasal Ophthalmic Oral Otic Rectal Subcutaneous Sublingual Vaginal Unknown Other (specify in notes)
BID Continous Daily Every 12 hours Every 2 hours Every 4 hours Every 6 hours Every 8 hours Every morning Every other day HS One time dose PRN dose QID Stat dose TID Other (specify in notes)
Name of medication administered
Manufacturer of medication administered
Buccal Cutaneous, topical application Epidural Gastric Inhalation Intramuscular Intravenous Intrathecal Nasal Ophthalmic Oral Otic Rectal Subcutaneous Sublingual Vaginal Unknown Other (specify in notes)
Lot # of medication administered
BID Continous Daily Every 12 hours Every 2 hours Every 4 hours Every 6 hours Every 8 hours Every morning Every other day HS One time dose PRN dose QID Stat dose TID Other (specify in notes)
Was the suspected drug discontinued?
Yes No Unknown
Did adverse reaction abate after discontinuing suspected drug?
Yes No Unknown
Did adverse reaction reappear after reintroduction of suspected drug?
Yes No Drug was not re-introduced
Was a rescue drug used because of the adverse reaction?
Yes No Unknown
Acetylcholine esterase inhibitor
Atropine
Benedryl
Calcium IV
Dantrolene
Dextrose 50%
Diazepam
Digibind
Diphenhydramine
Epinephrine
Flumazenil
Glucagon
Kayexelate
Naloxone
Protamine
Steroids
Vitamin K
Other (specify)
Select all that apply
Is this a suspected intentional fall event?
Yes No Unknown/Not Applicable
This question applies to patients aged 5 and above
Adult Baby/Child drop Develpmental fall Other
Was the fall a physiological event fall?
Yes No
Yes No Unknown
Staff Visitor Family Another patient Student Resident Faculty
Did the patient sustain a physical injury as a result of the fall?
Yes No Unknown
What was the level of injury?
Minor Moderate (resulted in suturing, steri-strips, splinting, etc) Major (resulted in surgery, casting, traction, etc) Death
What type of injury was sustained?
Dislocation Fracture Intracranial injury Laceration requiring sutures Other
Were fall protocols / prevention strategies in place prior to the fall?
Yes No Unknown / no documentation
Identify any contributing factors at the time of the fall
Abnormalities of gait or balance
Altered elimination (urgency, frequency, incontinence)
Altered mental status / cognitive impairment
Behavioral / mental health issue
Depression
Dizziness / vertigo
Low glucose / sodium levels
Orthostatic hypotension
Patient did not call for help
Side effects of medication
Unable to rise or ambulate without assistance
Visual impairment
Grab bar or hand rail placement
Side rails found down
Items not within reach
Lighting
Lock for movable transfer equipment not set
Tripped / slipped
Other patient or environmental factions (specify)
Select all that apply
What was the procedure associated with this event?
*
When was the event discovered?
Before anesthesia started (or no anesthesia used) Before incision, or start of procedure After procedure started, but before procedure ended At Closure, if surgical operation Before patient left operating room or other procedure area During post-anesthesia care/recovery period After post-anesthesia recovery but before discharge After patient was discharted During anesthesia when no operation or procedure was performed Unknown
What was the total length of the procedure (i.e., induction of anesthesia to the end of anesthesia)?
Less than 1 hour Greater than or equal to 1 hour but less than 3 hours Greater than or equal to 3 hour but less than 5 hours Great than or equal to 5 hours Unknown
What was the patient's documented American Society of Anesthesiologists (ASA) Physical Classification System class?
Class 1 (normal healthy) Class 2 (patient with mild disease) Class 3 (patient with severe disease) Class 4 (severe disease that is a constant threat to life) Class 5 (morbund, not expected to survive without procedure) ASA classification was not documented
What type of anesthesia or sedation was used?
Select all that apply
What was the level of sedation?
Deep sedation or analgesia Moderate sedation or analgesia (conscious sedation) Minimal sedation (anxiolysis) No sedation Unknown
Who administered (or was scheduled to administer) the anesthesia?
*
Anesthesiologist Faculty Hygienist Other healthcare professional Resident Student Unknown N/A
What type of device was involved in the event?
Inplantable device Medical equipment (i.e. non-implantable device)
What type of medical equipment was involved in the event?
Blood glucose monitor Blood pressure monitor Defibrillator Infusion pump Nitrous machine Oxygen source Ventilator Wheelchair other (specify)
At the time of the event, was the device placed within the patient's tissue
Yes No Unknown
Today M-D-Y
Did the event result in the device being removed?
Yes No Unknown
Today M-D-Y
Which of the following best describes the event or unsafe condition?
Device failure Operator error Combination or interactin of device failure and operator error Unknown
Which of the following best describes the device's involvement in the event?
Defect/failure directly impacted the patient Defect/failure was precursor to event that reached the patient Defect/failure created a near miss Defect/failure created an unsafe condition Unknown
What type of operator error?
Jure-rigging/workaround/force-fitting/defeating fail-safe/etc Selection of inappropriate device Mis-setting/mis-programming/otherwise misusing the device Unknown Other (specify)
Did the event involve resuse of a device intended for single use (including use of a reprocessed single-use device)?
Yes No Unknown
Was the device removed from service?
Yes No Unknown
Student Resident Faculty Dental Assistant Hygienist Administrative staff Other SDM personnel Other (specify)
What was the procedure associated with this event?
If known, enter ICD-9-CM procedure code associated with this event
What was the medical or surgical specialty of the provider who performed the procedure (or was scheduled to perform the procedure)?
Oral Surgery Periodontics Endodontics Orthodontics Diagnosis and Treatment Planning Emergency Implant Oral Medicine Oral Pathology Pediatrics Prosthodontics Radiology Restorative Screening Other
Was the procedure performed as an emergency?
Yes No Unknown
When was the event discovered?
Before anesthesia started (or no anesthesia used) Before incision, or start of procedure After procedure started, but before procedure ended At closure, if surgical operation Before patient left operating room or other procedure area During post-anesthesia care / recovery period After post-anesthesia recovery but before discharge After patient was discharged During anesthesia when no operation or procedure was peroformed Unknown
What was the patient's documented American Society of Anesthesiologists (ASA) Physical Classification System class?
Class 1 (normal healthy) Class 2 (mild disease) Class 3 (severe disease) Class 4 (severe disease that is a constant threat to life) Class 5 (moribund, not expected to survive without procedure) ASA classification was not documented
What type of anesthesia or sedation was used?
General anesthesia Regional anesthesia (nerve blocks, etc) Local or topical anesthesia Sedation only None
Who administered (or was scheduled to administer) the anesthesia?
Anesthesiologist Faculty Hygienist Other healthcare professional Resident Student Unknown
Yes No Unknown
Medical record number/ID of source individual if known
How many skin integrity issues (of this type) would you like to record?
*
5 4 3 2 1
Issue 1: When was skin integrity issue acquired?
Admitted with identified skin integrity issue New issue occurring < 24h after admission New issue occurring >= 24h after admission Unknown
Issue 1: Location of skin integrity issue
Head Face Upper back - right Upper back - left Lower back - right Lower back - left Chest - right Chest - left Abdomen - right Abdomen - left Buttock - right Buttock - left Arm - right Arm - left Leg - right Leg - left Foot - right Foot - left Other (specify)
Issue 2: When was skin integrity issue acquired?
Admitted with identified skin integrity issue New issue occurring < 24h after admission New issue occurring >= 24h after admission Unknown
Issue 2: Location of skin integrity issue
Head Face Upper back - right Upper back - left Lower back - right Lower back - left Chest - right Chest - left Abdomen - right Abdomen - left Buttock - right Buttock - left Arm - right Arm - left Leg - right Leg - left Foot - right Foot - left Other (specify)
Issue 3: When was skin integrity issue acquired?
Admitted with identified skin integrity issue New issue occurring < 24h after admission New issue occurring >= 24h after admission Unknown
Issue 3: Location of skin integrity issue
Head Face Upper back - right Upper back - left Lower back - right Lower back - left Chest - right Chest - left Abdomen - right Abdomen - left Buttock - right Buttock - left Arm - right Arm - left Leg - right Leg - left Foot - right Foot - left Other (specify)
Issue 4: When was skin integrity issue acquired?
Admitted with identified skin integrity issue New issue occurring < 24h after admission New issue occurring >= 24h after admission Unknown
Issue 4: Location of skin integrity issue
Head Face Upper back - right Upper back - left Lower back - right Lower back - left Chest - right Chest - left Abdomen - right Abdomen - left Buttock - right Buttock - left Arm - right Arm - left Leg - right Leg - left Foot - right Foot - left Other (specify)
Issue 5: When was skin integrity issue acquired?
Admitted with identified skin integrity issue New issue occurring < 24h after admission New issue occurring >= 24h after admission Unknown
Issue 5: Location of skin integrity issue
Head Face Upper back - right Upper back - left Lower back - right Lower back - left Chest - right Chest - left Abdomen - right Abdomen - left Buttock - right Buttock - left Arm - right Arm - left Leg - right Leg - left Foot - right Foot - left Other (specify)
Which of the following best describes the event or unsafe condition?
Device failure Operator error Combination or interaction of device failure and operator error Unknown
Which of the following best describes the device's involvement in the event?
Defect/failure directly impacted the patient Defect/failure was precursor to event that reached the patient Defect/failure created a near miss Defect/failure created an unsafe condition Unknown
What type of operator error?
Jury-rigging/workaround/force-fitting/defeating fail-safe/etc Selection or use of an inappropriate device Mis-setting/mis-programming/otherwise misusing device Unknown Other (specify)
Did the event involve resuse of a device intended for single use (including use of a reprocessed single-use device)?
Yes No Unknown
Was the device removed from service?
Yes No Unknown
Was a rapid response team or additional assistance requested from specially trained individual(s)?
Yes No Unknown
Identify type of restraint and/or equipment involved
Select all that apply
Was patient continuously observed?
Yes No Unknown
Were assessments completed at appropriate intervals?
Yes No Unknown
Was the SDM Rapid Response Team activated?
*
Yes
No
N/A
Was red phone functional?
*
Yes
No
N/A
Was campus dispatch (EMS) notified in absence of SDM Rapid Response Team?
*
Yes
No
N/A
Was campus dispatch (EMS) notified due to the patient's condition?
*
Yes
No
N/A
How quickly did the SDM Rapid Response Team respond?
*
How quickly did Campus Polie and/or EMS respond?
*
was x4-4444 used to notify campus dispatch?
*
Yes
No
N/A
Was 911 called directly?
*
Yes
No
N/A
PATIENT, PERSONNEL & VISITOR SAFETY
Did SDM Rapid Response Team secure the area and direct unnecessary individuals away from the scene? Did SDM personnel maintain the patient's privacy?
*
Yes
No
N/A
If present, were family members or others escorted to a confidential area?
*
Yes
No
N/A
EQUIPMENT AND SAFETY FEATURES
Was CPR (cardio pulmonary resuscitation) initiated?
*
Yes
No
N/A
Did the staff know where the emergency equipment and supplies are located?
*
Yes
No
N/A
Was the Code Cart brought to the scene?
*
Yes
No
N/A
Did staff identify issus with the following?
*
Yes
No
N/A
If so please describe under event detail
Were vital signs and treatments documented in the electronic health record?
*
Yes
No
N/A
Was a copy of the patient's medical history & face sheet sent w/EMS?
*
Yes
No
N/A
Was an occurrence report completed?
*
Yes
No
N/A
Do you have additional attachments?
Yes
Reviewer additional attachment
harm caused reached the individual Near Miss
1 - Unsafe Condition 2 - Near Miss
3 - No harm evident, physical or otherwise 4 - emotional distress or inconvenience 5 - additional treatment
6 - temporary harm 7 - permanent harm 8 - Severe Permanent Harm 9 - death
What prevented the near miss from reaching the patient?
*
Failsafe designed into the process/safeguard worked effectively Individual who made the error noticed and recovered Spontaneous action by another practitioner or staff member Action by the patient or patient's family Action by SDM personnel Other Unknown
How long after the incident was harm assessed?
*
within 24 hours after 24 hours but before 3 days 3 days or more unknown
Was any intervention attempted to prevent, reverse, or halt the progression of harm?
Yes No Unknown
Which of these interventions (rescues) were performed?
Who was Notified?
*
Administration Staff Dental Assistant Dental Resident Dental Student Dentist Dispensary Staff Facilities Staff Front desk staff Finance staff Hygienist Manager Oral Surgeon Other Patient Advocate Patient Liaison Security Technologist/Technician (Lab, X-ray, etc) Volunteer
Would you like to complete Manager Review?
Yes
No
QR Manager Review Review Complete