Dd Form 2852 - Patient Movement Event/near Miss Report
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1
2PATIENT MOVEMENT EVENT/NEAR MISS REPORT
(Information placed on this form is confidential and privileged in accordance with 10 U.S.C. 1102.
Do not file or refer to this form in a patient record.)
PRIVACY ADVISORY: When completed, this form contains personally identifiable information and personal health information and should be protected in
accordance with DoD 5400.11-R (the DoD Privacy Program).
Prepare this form to document events that resulted in or had the potential to result in harm to anyone in the PM system.
NOTE: If completed by ASF or other MTF staff follow local MDG incident reporting policy in addition to completing this form.
SECTION I - PERSON COMPLETING FORM
1
.a. LAST NAME
b. FIRST NAME
c. MIDDLE INITIAL
d. GRADE
e. UNIT OF ASSIGNMENT
f. TELEPHONE NUMBER
g. EMAIL ADDRESS
h. SIGNATURE
(Include area code)
i. WITNESSES TO EVENT
(1) NAME/GRADE
(2) UNIT OF ASSIGNMENT OR ADDRESS
(3) TELEPHONE
(4) EMAIL ADDRESS
j. PMQ-R GENERATED LOG NUMBER (For PM Safety Manager):
SECTION II - GENERAL INFORMATION
2. DATE
/
(YYYYMMDD)
3. LOCATION OF EVENT
(Be specific)
TIME
OF EVENT
(Z)
a. MTF:
d. EN ROUTE HOLDING AREA:
g. AIRCRAFT (In-flight):
h. OTHER:
b. ASF/ASTS:
e. GROUND TRANSPORT:
c. OTHER RON:
f. AIRCRAFT (Ground):
4.
b. SUBMITTING UNIT
a. MAJCOM RESPONSIBLE FOR MISSION
5. DID THIS EVENT RESULT IN DEATH, NEAR DEATH OR HOSPITALIZATION?
(X appropriate block)
YES
NO
IF YES, CONTACT THE PMRC AS SOON AS POSSIBLE TO REPORT EVENT.
6. PERSON AFFECTED OR POTENTIALLY AFFECTED BY THIS EVENT
(X appropriate block)
PATIENT
PAX
CREW
FACILITY STAFF
ATTENDANT
CCATT MEMBER
7. EVENT CATEGORY
(X as applicable)
a. MEDICATION
MEDICATION ERROR
NARCOTIC NOT ACCOUNTED FOR
SELF MEDICATION ISSUE
b. STATUS CHANGE
AE PROTOCOL USED
DEATH IN-FLIGHT
SEIZURES
ALLERGIC REACTION
DEATH WITHIN 24 HOURS
SHORTNESS OF BREATH
BIRTH
DESATURATION
SUICIDE
CARDIAC/RESPIRATORY ARREST
MEDICATION RESPONSE
TRANSIENT/MILD STATUS CHANGE
CHEST PAIN
c. PATIENT PREP
ATTENDANT ISSUES
MEDICATION
SUPPLIES
DOCUMENTATION OF CARE
ORDERS
TREATMENT NOT DONE PRIOR TO FLIGHT
EQUIPMENT
PAPERWORK
d. OTHER
AIRCRAFT AMPERAGE
COMMUNICATION
NO MEALS SUPPLIED
AIRCRAFT EMERGENCY
FLIGHT CREW EQUIPMENT/MSN DUTY
PMRC
AIRCRAFT MAINTENANCE DELAY
TRANSPORTATION ISSUES
INDIVIDUAL BODY ARMOR
BAGGAGE ISSUES
MEDICAL DELAY
e. PATIENT HANDOFF
INADEQUATE PATIENT HANDOFF
NO PATIENT HANDOFF
f. INFECTION CONTROL
BLOOD OR OTHER BODY FLUID EXPOSURE
TRANSPORTATION OF INFECTIOUS PATIENT
g. ASF/RON SPECIFIC
ASF/RON TRANSPORTATION ISSUES
h. ANTI-HIJACK
COMPLETED INCORRECTLY
NOT COMPLETED
ACTUAL
POTENTIAL
i. INJURY
j. EQUIPMENT
TYPE OF EQUIPMENT
MODEL NUMBER/SERIAL NUMBER (If applicable)
NOT APPROVED FOR FLIGHT
WAIVER REQUIRED
FAILURE/MALFUNCTION
DD FORM 2852, FEB 2011
PREVIOUS EDITION IS OBSOLETE.
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