Narrative
Do you think this incident was preventable?	Yes No
Incident Description Please include as much detailed information as possible.
Contributing Factors:
Lessons Learned:

Cognitive Factors:
Did I accept this patient as a "hand off", or was the diagnosis suggested verbally by the patient?	Yes No
Did this patient seem to fit a classic pattern that turned out to be incorrect?	Yes No
Did I consider a cause besides the first seemingly obvious one?	Yes No
Is this a patient I do not like, or like too much, for any reason?	Yes No
Was I interrupted, distracted, or otherwise cognitively overloaded while caring for this patient?	Yes No
Any additional information related to cognitive elements present in this case:
Emergency Manual Usage:
In responding to this event, did the team use any emergency manual? (a.k.a cognitive aid, checklist)	Yes No

Classification and Harm Scale

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Use the list below to properly classify the incident. Utilize Search and Category Filter for finding appropriate category.
Level of Harm to Patient (per AHRQ Scale):

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.

Optional Data
Is this a real case or a test?	Real Test
Patient	... Male Female No Patient Involved Multiple People Involved
Age	... 1 to 17 years 18 to 34 years 35 to 49 years 50 to 64 years 65 to 79 years 80 years or older
Habitus	... Underweight (BMI < 18.5) Normal (BMI 18.5 - 25) Overweight (BMI > 25) Obese (BMI > 30) Morbidly Obese (BMI > 40)
ASA Physical Status	... I IE II IIE III IIIE IV IVE V VE VI
Area	... OR Procedure Center OB Ambulatory Surgery Center Preop Clinic Preop Holding PACU Postop Ward ICU Triage/emergency room Out of Hospital Other Unknown
Time Incident Occurred	... Day (6AM-4PM) Evening (4PM-10PM) Night (10PM-6AM)
Anesthesia Staffing	Immediate Provider Supervising Provider Other Provider ... Anesthesiologist Anesthesia Fellow Anesthesia Resident CRNA Anesthesia Assistant PA OR Nurse Other ... Anesthesiologist Anesthesia Fellow Anesthesia Resident CRNA Anesthesia Assistant PA OR Nurse Other ... Anesthesiologist Anesthesia Fellow Anesthesia Resident CRNA Anesthesia Assistant PA OR Nurse Other
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