Nasa Form F6 - Patient Safety Reporting System (Psrs) Report Form - California
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3Patient Safety Reporting System (PSRS) Report Form
Please fill in all blanks. This section will be returned to you.
IDENTIFICATION STRIP:
NO RECORD WILL BE KEPT OF YOUR IDENTITY.
(SPACE BELOW RESERVED FOR PSRS REPORT RECEIPT STAMP)
TELEPHONE NUMBERS where we may reach you for further
details of this occurrence:
HOME
Area
No.
-
Ho
urs
Area
No.
-
Ext.
Hours
WORK
PLEASE SUPPLY A BRIEF DESCRIPTION OF THE
EVENT OR SITUATION YOU ARE REPORTING
ADDRESS to which you want your confirmation of report receipt mailed:
NAME
ADDRESS / PO BOX
D
ATE O
F OCCURR NCE
E
LOCAL TIME (24 hr. clock)
CITY
STATE
ZIP
INTENTIONALLY UNSAFE ACTS AND CRIMINAL ACTIVITY ARE NOT INCLUDED IN THE PSRS PROGRAM. YOUR NAME IS IMPORTANT SO YOUR ID STRIP
CAN BE RETURNED TO YOU. ALL IDENTITIES CONTAINED IN THIS REPORT WILL BE REMOVED TO ASSURE COMPLETE REPORTER ANONYMITY.
PLEASE FILL IN SPACES AND CHECK BOXES BELOW THAT APPLY TO THIS EVENT OR SITUATION YOU ARE REPORTING.
REPORTER INFORMATION AND EVENT BACKGROUND
What is your current position?
Type of facility:
How many years of health care
experience do you have?
Administration
(Director, QM, Patient
Hospital (including E.D.)
Safety, etc.)
(Position)
Outpatient Facility
Other:
Ancillary Care
(Rehab, RT, OT, PT,
How many years have you worked at
RD, etc.)
(Specify)
your facility?
Behavioral Medicine
What was your scheduled Shift?
(Position)
8 hours
36 hours on
Environ / Engineering Services
10 hours
48 hours on
How many years have you worked in
Laboratory
(Specify)
12 hours
Additional shift
your current position?
Nursing
24 hours on
Other _________
(RN, LVN, RNP, CRNA, etc.)
Pharmacy
(Specify)
This event occurred at:
Your participation in event:
Physician
(PA, Anesthesia, etc.)
(Specify)
Hours into shift _______
Involved
Change of shift?
Witnessed, not involved
Other:
Not involved, heard of or advised
of event
EVENT L
OCATION
OTHER FACTORS
(check all that apply)
Were there any environmental factors
W
here did the event occur?
that may have contributed to the event
Ancillary Services (Rehab, RT, OT,
Patient Room
(air quality, lighting, noise, etc.) ?
Pediatrics
PT, Dietary, etc.)
(Specify)
Behavioral
/ Mental Health
Pharmacy
Emergency Dept / Urgent Care
Provider Office
Radiology/Imaging
Hallway or ther Common Area
o
Were there any IT hardware or software
ICU / CCU / TCU / NICU
Surgical Sui
te
(OR / ASU / P
ACU)
factors that may have contributed to the
Laboratory / Pathology
Treatment / Exam Room
event (equipment malfunction, computer
Women’s Health
Maternal / Child
system down, etc.) ?
Other:
Nurses Stat
ion /
Med Room
(Specify)
EVENT DESCRIPTION — GO TO NEXT PAGE (2)
PSRS / NASA Form F6, November 2009
Page 1 of 2
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