EMS Event Report Form
Reporting Party (remains confidential)
Reporting Party Name:
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Title/Position:
Agency:
Phone Number:
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Phone
Email:
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Incident Information (complete as much information as is available)
Date of Incident:
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Time of Incident:
Location of Incident:
Receiving Facility (if any):
Incident/EHR Number:
Incident Reported To:
Person Reported To Title/Position:
Select all that apply to the issue you are reporting:
Sentinel Event (issue which DOES impact patient care/safety)
Unusual Event/Occurrence (issue which MAY impact patient care/safety)
Never Event (extended ambulance off-load time at hospital greater than 1 hour)
Exemplary Care
Vehicle Collision Involving Ambulance/EMS Response Vehicle Resulting In Injury
Issue with Staff (e.g., EMS Personnel, law enforcement, hospital, facility)
Other
Details of Event:
Did the sentinel event involve a medication error?
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Select or enter value
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Did the unusual event involve a medication error?
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Select or enter value
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Name of intended medication:
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Amount of intended medication:
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Name of administered medication:
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Amount of administered medication:
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Name of Receiving Hospital:
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Time ambulance arrived at destination:
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Time of transfer of care:
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Please provide a concise description of the event(s):
*
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