EMS Event Reporting Form

San Mateo County EMS Event Reporting

Please use this form to provide timely and pertinent information regarding an EMS event. The information submitted should originate from the provider(s) involved and may be submitted anonymously. Please note that anonymous reporting may impact the LEMSA's ability to respond to your concern. Please do NOT provide any protected health information (e.g., name, date of birth, or social security number of an EMS patient) with your submission. An EMS event number or date and address of the event will be sufficient. If you have questions or concerns, please contact the EMS Duty Officer through Public Safety Communications.

Reporting Party

Agency

Title/ Position

Phone Number

Phone

Incident information

Please complete as much information as possible.

Date of Incident

Time of Incident

Location of Incident

Receiving Facility (if applicable)

Incident Number/ EMS Event Number

Incident Reported To

Title of Person Incident Reported To

Type of Incident (select all that apply)

Please refer to OPS 37 - EMS Event Reporting for detailed definitions of each category listed below:

Sentinel Event (any issue which DOES impact patient care - IMMEDIATE reporting required (e.g., administered incorrect medication or dose, deviation from policy/ protocol that resulted in patient hard or compromised public safety, etc.)

Adverse Event (any issue which MAY impact patient care - reporting required within 24 hours (e.g., drew up incorrect drug but did not administer it, equipment failure that may have compromised patient or public safety, etc.)

'Never Event' (e.g., extended patient offload time at a hospital greater than one (1) hour)

Vehicle collision involving an ambulance with a patient onboard

Issue with staff (e.g., EMS personnel, law enforcement, hospital or facility)

Exemplary performance/ recognition

Other

Description of Incident

File Upload

Please upload any documentation necessary (i.e., photos, etc.)

Drop your files here

Anonymous Submission

If you select yes, your identifiable information (e.g., name, email address, and phone number) will remain confidential and shall not be shared with any person or entity outside of the EMS Agency.

Yes

Send me a copy of my responses

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