AIRS Injury - Case Entry QCA AQI

INJURY REPORT
All reports to AIRS are maintained as privileged and confidential within AQI's patient safety evaluation system.

Incident Description
Please include as much detailed information as possible.

Age

Practice setting that injury occurred

Type of Injury

Awkward posture (includes reaching, bending, twisting, stretching, flexion, kneeling, crouching, crawling, etc.)

Burn (includes electric, cautery, etc.)

Equipment (includes ceiling-mounted monitor, ventilator, patient bed, pyxis machine, etc.)

Lifting

Needle stick

Patient cause (includes slap, hit, verbal, etc.)

Slip and fall

Transport and/or pushing or pulling heavy load

Other

Body location of injury (Select all that Apply)

Head (includes the brain, face, ear, eye, nose, and jaw)

Neck (includes the cervical spine region)

Back (includes the thoracic, lumbar and sacral region of the back)

Upper extremities (includes the shoulder, arm, wrist, and hand)

Lower extremities (includes the hip, leg, ankle, and foot)

Other

Report Confidentially Option

If you elect this option and provide your contact information, you will be provided with a reference number for your report.
This reference number can be used to review and modify your case at a later date by selecting the 'Review Previous Report' button.

First Name

Last Name

Year of Birth:

Gender:

Role:

Institution/Facility:

Facility Type:

State:

City:

Email recipients: