All reports to AIRS are maintained as privileged and confidential within AQI's patient safety evaluation system.
Average time for form completion is 3-4 minutes

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NARRATIVE
Do you think this incident was preventable? Yes No

Incident Description
Please include as much detailed information as possible.
Contributing Factors

Lessons Learned

Category ... Administrative Airway Management Anesthetic/Operative Complications Blood Cardiac Documentation Equipment Immunological Infrastructure/System Medication Mortality Neuro Pulmonary/Respiratory Regional Anesthesia Renal Vascular Complications

Level of Harm to Patient ... Unsafe Condition - Any circumstance that increases the probability of a patient safety event. Near Miss - Event occurred but did not reach patient. No Harm - Reached patient, but no harm was evident. Emotional Distress or Inconvenience - Mild and transient anxiety, pain, or physical discomfort. Additional Treatment - Injury limited to additional intervention during admission but no other injury. Temporary Harm - Bodily or psychological injury, but likely not permanent. Permanent Harm - Lifelong bodily or psychological injury or increased susceptibility to disease. Severe Permanent Harm - Severe lifelong bodily or psychological injury or disfigurement. Death - Death at the time of the assessment.

Procedural Service Involved ... General Surgery Cardiothoracic Surgery Vascular Surgery Orthopedic OHNS OMFS Plastics ENT Neurosurgery Ophthalmology Transplant Surgery Trauma Surgery OB/GYN GI Urology Interventional Radiology Imaging Anesthesia Only Other Unknown