Escalation Event
All Forms
Escalation Event
Section 1: Initiator Details
Initiator name
*
Initiator's email
Initiator department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
Date of occurrence
*
Time of occurrence
*
Location of occurrence
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
Other
Other
*
Room #
Additional details
Occurrence related to
*
Patient
Visitor
Employee
Contractor
Name
*
DOB
FIN number
Name
*
Related patient name
Phone
*
Address
Name
*
Department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
Other
Name
*
Related department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
Other
Phone
*
Company name
Section 2: Escalation Details
Type of altercation
*
Verbal
Physical
Abusive
Altercation with
*
Patient
Employee
Self
Visitor
Contractor
Injury
Yes
No
Who was/were injured ?
Patient
Employee
Self
Visitor
Contractor
Where was the injury ?
Suicide attempt
Yes
No
Contraband
Yes
No
Explain the type of contraband in description of event/incident section
Security informed
Yes
No
Restraint
Yes
No
Seclusion
Yes
No
Law enforcement called
Yes
No
Did they respond ?
Yes
No
Patient discharged with law enforcement
Yes
No
MET team called
Yes
No
Did they respond ?
Yes
No
Patient put on 5150 hold
Yes
No
Patient discharged with MET team
Yes
No
Select all the codes that were called
*
Code Red
Code Blue
Code Yellow
Code White
Code Pink
Code Silver
Code Green
Code Purple
Code Assist
Code MedAlert
Code Triage
Code Disaster
No code was called
Witnesses
Yes
No
Add Witness
Description of event/incident
Family/Caregiver notified
*
Yes
No
Name
Relation
Date
Time
Reason
Physician notified
*
Yes
No
Physician name
Select
Matab Singh MD
Romona Dolan PA
William Bichai MD
Juan Sosa MD
Ravi Kapadia MD
Ruben Nieto MD
Mandeep Bagga MD
Mushtaq Ahmed MD
Oriente Esposo MD
Type of physician intervention
Change Patient Care Plan
Use of Restraint
Seclusion
Patient Assessment
Date
Time
Reason
Submit
