Error Reporting - Mehr Outpatient Surgical and Infertility Center

Patient safety

Your report helps prevent future incidents

This form is confidential and is used only to review, learn from, and improve clinical processes. Patient and staff names are optional.

Confidential Record facts accurately and objectively.

Record when, where, and what happened.

Patient name optional

Patient file number optional

Department where the event occurred

Shift

Event date

Brief description of the event

Maximum 2,000 characters

Identify the roles involved and the resulting impact.

Position of person involved

Reporter position

Name of person involved optional

Resulting impact

Was the event preventable?

Likelihood of recurrence

Choose the error type, subtype, and likely cause.

Error type

Error subtype

Likely cause

Record actions taken and suggestions for prevention.

Additional details optional

Interventions or actions taken to reduce harm optional

Lessons learned and suggestions to prevent recurrence optional

Enter the result below to confirm

9 + 6 = ?