Treatment/Procedure Event
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Treatment/Procedure 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
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Date of occurrence
*
Time of occurrence
*
Other Initiator Department
*
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
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Other
*
Room #
Additional details
Section 2: Occurrence Details
Event / Incident Reason
*
Found unresponsive
Unanticipated death
Wrong patient
Treatment/test missed
Treatment/test delayed
Procedure delayed
Unexpected transfer to ICU
Transfer to higher level of care
Delay of care
Discharge error/complication
Self-extubation
Lost lab specimen
Wrong treatment/procedure
Orders missed/delayed
Patient NPO/food served
Other
Other Event / Incident Reason
*
Description of event
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