Screenshot 2023-05-14 at 3.00.15 PM
Screenshot 2023-05-14 at 3.00.15 PM
Screenshot 2023-05-14 at 3.00.15 PM
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?@OLIRCG? /OMJ?HMCIH
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?@IN;RCG?MI>COG 2C;F AG , $
?@N;TC>CG? 2C;F AG , $
J?HN;BS>L;N?
?@NLC;RIH?MI>COG 2C;F AG , $
?@OLIRCG?MI>COG 2C;F
GA , $
?JB;F?RCHGIHIBS>L;N? ;JMOF?
GA , $
?JBL;>CH? ;JMOF?
GA , $
?JB;F?RCH /OMJ?HMCIH
GAGF *,
GIHIBS>L;N?
*0%
%*"!0%+1/ .1#
&G;8EAG<5<BG<6F
/J?=NCHIGS=CH$( 2C;F AG , $
/JCL;GS=CH 0;<F?N
%1 , $
2;H=IGS=CH$( 2C;F
GA , $
IFCMNCH 2C;F
%1 , $
/OFJBIG?NB;N?
/I>COG
(CH?TIFC> 0;<F?N
GA , $
(CH?TIFC> ,L?GCR?>;A
GA
GF;A , $
(CH?TIFC> /OMJ?HMCIH
GAGF
GFINNF? , $
*H?9BA4@<78F4A7+E<@8G;BCE<@
0LCG?NBIJLCG 0;<F?N
GA
GA , ,$ $
/OF@;G?NBIR;TIF?
0LCG?NBIJLCG /OMJ?HMCIH
GA
GA , ,$ $
/OF@;G?NBIR;TIF? GF
GFINNF?
0LCG?NBIJLCG GJIOF?
GA
GA , $
/OF@;G?NBIR;TIF?
/OF@;>C;TCH? 0;<F?N
GA *,
AG<GH58E6H?BHFEH:F
S=FIM?LCH? ;JMOF?+.0;<F?N
GA , $
!NB;G<ONIF$( 0;<F?N
GA , ,$ $
!NBCIH;GC>? 0;<F?N
GA *,
%MIHC;TC>%*$ 0;<F?N
GA , $
%MIHC;TC>%*$ /SLOJ
GAGF
GFINNF? *,
%MIHC;TC>%*$ GJIOF?IL2C;F
GA *,
,;L;
;GCHI 0;<F?N
GA , $
M;FC=SF;N?MI>COG
%+ ,%#),*
'B?L8A8AG<9HA:4?F
GJBIN?LC=CH 2C;F
GA , $
!H=;JMOF;N?>FCJIMIG?M
*SMN;NCH 0;<F?N
%1 *,
*SMN;NCH /OMJ?HMCIH
%1 , ,$ $
GF
GF
@<74MB?8AG<9HA:4?F
"FO=IH;TIF? 0;<F?N+.;JMOF?
GA , $
"FO=IH;TIF? /OMJ?HMCIH
GAGFGF , $
*0%
%*"!0%+1/ .1#
"FO=IH;TIF? 2C;F
GA , $
%NL;=IH;TIF? ;JMOF?
GA , $
'?NI=IH;TIF? 0;<F?N
GA *,
2ILC=IH;TIF? 2C;F
GA *,
2ILC=IH;TIF? 0;<F?N
GA *,
)C=IH;TIF? +L;F#?F
GAAG
, $
AG0O<?
&G;8EAG<9HA:4?F
#LCM?I@OFPCHGC=LIHCT?> 0;<F?N
GA *,
#LCM?I@OFPCHGC=LIHCT?> /OMJ?HMCIH GAGF *,
GF
0?L<CH;@CH? 0;<F?N
GA , $
"FO=IH;TIF? ;JMOF?
GA *,
6;<AB64A7<AF
;MJI@OHACH=?N;N? 2C;F
GA *,
)C=;@OHACH/I>COG 2C;F
GA *,
%+ - )#),*
EH:F9BE8EC8F *<@C?8K4A7-4E<68??41BFG8E-<EHF8F
=S=FIPCL 0;<F?N
GA , ,$ $
=S=FIPCL /OMJ?HMCIH
GAGFGF , $
=S=FIPCL 2C;F
GA , $
2;F;=C=FIPCL$( 0;<F?N
GA , $
EH:F9BEH@4A @@HAB789<6<8A6L-<EHF
%H6?8BG<78)8I8EF8+E4AF6E<CG4F8 A;<5<GBEF%)+ F
6C>IPO>CH? ;JMOF?
GA , $
TC>INBSGC>CH? 60
EH:F9BELGB@8:4?BI<EHF
*0%
%*"!0%+1/ .1#
#;H=C=FIPCL 2C;F
GA , $
2;FA;H=C=FIPCL$( 0;<F?N
GA , $
"IM=;LH?N %H@OMCIH2C;F GAGF
GF *,
INNF?
EH:F9BE)8FC<E4GBEL*LA6LG<4?-<EHF
.C<;PCLCH 2C;F@IL;?LIMIFCHB;F;NCIH AG *,
0LC<;PCLCH ILH?<OFCT;NCIH
.C<;PCLCH ;JMOF?
GA , $
,;FCPCTOG;< 2C;F
GA , $
EH:F9BE-<E4?;8C4G<G<F
!HN?=;PCL 0;<F?N
GA , $
>?@IPCL>CJCPIRCF 0;<F?N
GA , $
.;FN?AL;PCL 0;<F?N
GA *,
%+ ')&+&1&#),*
AG<@4?4E<4?F
LN?GCMCHCH ;JMOF?
GA *,
LN?MOH;N? 0;<F?N
GA *,
LN?MOH;N? GJIOF?
GA *,
BFILIKOCH? 0;<F?N
GA
, ,$ $
JBIMJB;N? GA<;M?
BFILIKOCH? /SLOJ
GA<;M?GF
, ,$ $
JBIMJB;N?
GFINNF?
BFILIKOCH? GJIOF?
GA ,
<;M?
)?@FIKOCH?$( 0;<F?N
GA , $
,LCG;KOCH? 0;<F?N GA , ,$ $
JBIMJB;N?
(OG?@;HNLCH? GA
LN?MOH;N? 0;<F?N
GA
, $
/OF@;>IRCH? GAGA
,SLCG?B;GCH?
LN?MOH;N?/OF@;>IRCH? 0;<F?N
GA
, $
,SLCG?B;GCH? GAGA
LN?G?NB?L GJIOF?
GA , $
+48A<6<78F4A7*6;<FGBFB@<6<78F
*C=FIM;GC>? 0;<F?N
GA *,
,L;TCKO;HN?F 0;<F?N
GA , ,$ $
EH:F9BEL74G<7<F84F8
F<?H>;TIF? 0;<F?N
GA , $
F<?H>;TIF? 0;<F?N
GA , $
<?4E<6<78F
*0%
%*"!0%+1/ .1#
%P?LG?=NCH 0;<F?N
GA *,
C?NBSF=;L<;G;TCH? 0;<F?N
GA , $
=CNL;N?
;4CG8E
EH:FHF87<AG;8GE84G@8AGB97<FBE78EFB9G;8
%&) %*0*+$
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B78%B G8@*C86<9<64G<BA *GE8A:G;
BE@
EH:FHF87<AG;8GE84G@8AGB97<FBE78EFB9G;8%&) %*0*+$
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$OG;HMIFO<F?CHMOFCH 2C;F
%1GF , ,$ $
.?AOF;L
GF
$OG;HCMIJB;H?CHMOFCH 2C;F
%1GF , ,$ $
*,$
GF
%HMOFCH#F;LACH? 2C;F
%1GF
GF , $
!* +.%*!/5/0!)
!* +.%*!/5/0!)
,CIAFCN;TIH? 0;<F?N GA *,
+0)& %%+ +0)& ),*
+;LEB<7BE@BA8F
0BSLIRCH?MI>COG 0;<F?N G=A , $
0BSLIRCH?MI>COG 0;<F?N
G=A , ,$ $
0BSLIRCH?MI>COG 0;<F?N
G=A , ,$ $
(?PINBSLIRCH? GJIOF?
G=A , $
MI>COG
AG<G;LEB<7EH:F
;L<CG;TIF? 0;<F?N GA , ,$ $
,LIJSFNBCIOL;=CF 0;<F?N
GA , $
LC8EC4E4G;LEB<7<F@
CH;=;F=?N$F 0;<F?N
GA , $
CH;=;F=?N$F 0;<F?N
GA , $
&)+ &*+)& *
"FO>LI=ILNCMIH? 0;<F?N
G=A , $
;=?N;N?
,L?>HCMIFIH? 0;<F?N GA , ,$ $
,L?>HCMIFIH? 0;<F?N
GA , ,$ $
?R;G?NB;MIH? 0;<F?N
G=A , $
?R;G?NB;MIH? GJIOF? GA , ,$ $
$S>LI=ILNCMIH? 0;<F?N
GA , $
$S>LI=ILNCMIH? GJIOF?IL2C;F
GA , ,$ $
)?NBSFJL?>HCMIFIH? GJIOF? IL2C;F
GA , $
'EB:8FGB:8AF
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GA , $
$S>LIRSJLIA?MN?LIH? GJIOF?
GA , $
B?R;HI;N?
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;=?N;N?
!* +.%*!/5/0!)
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.?=IG<CH;HNBOG;H ?PC=?
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@IFFC=F?MNCGOF;NCHA
BILGIH?"IFFCNLIJCH<?N;
LCBG;4?4@<6BE@BA8F
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GJIOF?
G=A *,
L?F?;MCHA@;=NIL ."
#H.B;H;FIAO? ?=;J?JNSF? GJIOF? GA , $
#IH;>IL?FCH #IH;>INLIJBCH
2C;F
G=A , $
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G=A *,
L?F?;MCHABILGIH? 0.$
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GJIOF?
G=A *,
L?F?;MCHABILGIH? #$.$
'BFG8E<BE'<GH<G4ELBE@BA8F
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%1GF ,
?MGIJL?MMCH;=?N;N? CMCHN?AL;NCHA
G=A , $
0;<F?N
?MGIJL?MMCH;=?N;N? CMCHN?AL;NCHA
G=A ,
0;<F?N
?MGIJL?MMCH;=?N;N? 0;<F?N
G=A *,
?MGIJL?MMCH;=?N;N? *;M;F/JL;S
G=A
GF *,
),*+ %&%$+&# *$
;F=CNIHCH/;FGIH
GJIOF?
%1 , $
/;F=;NIHCH
CMI>COGJ;GC>LIH;N? 2C;F GA *,
/NLIHNCOG.;H?F;N? /;=B?N AG , $
6IF?>LIHC=;=C> 2C;F GA , $
6IF?>LIHC=;=C> ,L?GCR?>%H@OMCIH GA
GF , $
F?H>LIH;N?MI>COG 0;<F?N
GA , $
0?LCJ;L;NC>? 2C;F
G=AGF , $
&+)%&) %),*
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;<?LAIFCH? 0;<F?N
G=A *,
'<GH<G4ELBA47BGEBC;<AF A;<5<GBEF
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CHIJLIMNIH? ?LPC=;FA?F
G=A *,
>CMJIM;<F?/SCHA? GF
#!*%0+1.%*.5/5/0!)
CHIJLIMNIH?@IL GJIOF? GA , $
?RNL;;GHCINC=
)CMIJLIMNIF 0;<F?N
G=A , $
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)?NBSF?LAIHIPCH?G;F?;N? GJIOF?
G=A , ,$ $
FJLIMN;>CF,LIMN;AF;H>CH GJIOF?
G=A , $
!,?>C;NLC=>IM?
;L<IJLIMN0LIG?NB;GCH? GJIOF?
G=A , $
$LB@8GE<4?)8?4K4AGF
.CNI>LCH?$( 0;<F?N
GA , $
.CNI>LCH?$( GJIOF?
GA , $
EH:F9BE*8<MHE8'E8I8AG<BA<A6?4@CF<4
);AH?MCOGMOF@;N? GJIOF?IL
GF , $
2C;F
+)+$%+&- %#
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AG<9HA:4?EH:F
FINLCG;TIF? 2;ACH;F=L?;G
AG *,
!=IH;TIF?HCNL;N? 2;ACH;F=L?;G
AG *,
)C=IH;TIF?HCNL;N? 2;ACH;F=L?;G
AG *,
%GC>;TIF? >?LCP;NCP? 2;ACH;F0;<F?N
GA , ,$ $
;4CG8E
EH:FHF87<AG;8GE84G@8AGB9
$# %%+ **%
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BF4:8
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$$,%&*,'')** &%
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OMOF@;H 0;<F?N GA , $
;LGOMNCH? 2C;F
GA *,
BFIL;G<O=CF 0;<F?N GA , $
S=FIJBIMJB;GC>? 0;<F?N
GA , $
S=FIJBIMJB;GC>? 2C;F
GA , $
%))1*+/1,,.!//%+*
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GA , $
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0B;FC>IGC>? ;JMOF?
GA *,
%@IM@;GC>? 2C;F AG , $
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GA *,
$(
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EH:F9BE,EBG;8?<4?+BK<6<GL
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GA , $
LGBGBK<6AG<5<BG<6F
F?IGS=CH GJIOF? GA
, $
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G=A , $
;OHILO<C=CH$( 2C;F
GA , $
IRILO<C=CH$( 2C;F
GA , $
IRILO<C=CH$( 2C;F
GA , $
!JCLO<C=CH$( 2C;F
GA , $
!JCLO<C=CH$( 2C;F
GA , $
)CNIGS=CH 2C;F GA *,
)CNIGS=CH 2C;F
GA *,
)CNIGS=CH 2C;F
GA *,
%))1*+/1,,.!//%+*
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#?G=CN;<CH? 2C;F
GA , $
#?G=CN;<CH? 2C;F AG *,
;L<IJF;NCH 2C;F
GA , $
(IGOMNCH? ;JMOF?
GA , $
%G;NCHC<G?MCF;N? ;JMOF?
GA , $
;M;NCHC<GIHIBS>L;N? 0;<F?N
GA , $
;M;NCHC< 0;<F?N
GA , $
GIHIBS>L;N?
*CFINCHC< 0;<F?N
GA , $
/IL;@?HC< 0;<F?N
GA , $
I=?N;R?F 2C;F
GA , $
I=?N;R?F 2C;F
GA , $
%LCHN?=;HBS>LI=BFILC>? 2C;F
GA *,
+R;FCJF;NCH 2C;F
GA , $
+R;FCJF;NCH 2C;F
GA , $
0L?NCHCIH ;JMOF?
GA *,
?P;=CTOG;< 2C;F
GA , $
?P;=CTOG;< 2C;F
GA , $
ILN?TIGC< 2C;F GA , $
'EBG8<A"<A4F8 A;<5<GBEF
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BS>LI=BFILC>?
!LFINCHC< I;N?>0;<F?N
GA , $
BS>LI=BFILC>?
!LFINCHC< I;N?>0;<F?N
GA , $
BS>LI=BFILC>?
BE@BA84AG4:BA<FGF
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GA , $
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GA , $
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"ILF;>>?LCHMNCFF;NCIH
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'EB:8FGB:8AF
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GA , $
BE@BA8AG4:BA<FGF
0;GIRC@?H=CNL;N? 0;<F?N
GA , $
H;MNLITIF? 0;<F?N GA , $
GCHIAFON?NBCGC>? 0;<F?N
GA *,
"FON;GC>? 0;<F?N
GA *,
+=NL?INC>? GJIOF?
G=A , $
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GA *,
0?LFCJL?MMCH=?N;N? 2C;F GA *,
;4CG8E
EH:F49986G<A:
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BF4:8
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EH:F49986G<A:%,+) + &%%#&&*,*+ +,+*
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GA *,
;JMOF? !F?G?HN;FCLIH
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GA , ,$ $
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"OG;L;N?"IFC=;=C>
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GF , $
/I>COGBFILC>? INNF?+.;A
GF , $
/I>COGBFILC>? INNF?+.;A
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GF , ,$ $
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GCHI;=C>M@IL INNF?
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EH:FHF87<AG;8GE84G@8AGB9
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_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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Error occurred but did not reach the patient.
Error reached the patient but did not cause harm.
Error reached the patient and required monitoring.
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Error reached the patient and resulted in temporary harm that required intervention.
Error reached the patient and contributed to patient’s death or morbidity (Immediately notify the Sentinel Event Committee in case patient died)
99105-@1/@5;:'-71:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Assessment: _____________________________________________________________________________________________
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_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Action taken complete Action taken incomplete Action taken not documented
Report forwarded/referred to: __________________________________________________________________
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