ANESTHESIOLOGIST INJURY FORM
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
...
21-40 years
41-60 years
>60 years
Gender
...
Woman or Female
Gender Nonconforming
Man or Male
Nonbinary
Prefer not to answer
Practice setting that injury occurred
...
Ambulatory Surgery Center
Emergency Room
Intensive Care Unit/Critical Care Unit
Obstetrics - Labor and Delivery
Operating Room
NORA
Preoperative Clinic
Preoperatrive Holding
Procedure Center
Post-Anesthesia Care Unit/Postoperative Ward
Other
Race
...
Asian
Black/ African American
White
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Prefer not to answer
Other
Ethnicity
...
Not Hispanic, Latino, Spanish Origin
Hispanic, Latino, Spanish Origin
Prefer Not to Answer
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 (specify below)
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 (specify below)
Other
Optional
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:
Role:
...
Anesthesiologist
Anesthesia Resident
CRNA
Anesthesia Assistant
PA
OR Nurse
Other
Institution/Facility:
Facility Type:
...
Freestanding Surgery Center
Small Community Hospital (less than 100 beds)
Medium Community Hospital (100-500 beds)
Large Community Hospital (over 500 beds)
Speciality Hospital
University Hospital
State:
unknown
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City:
Email recipients:
