Otolaryngology — Head & Neck Surgery
Quality Assurance

Best practice is to submit this form within 24 hours of event date.

Patient Last Name

Patient First Name

Patient Affiliation

Patient age at the time of the Incident:

Patient Age in YEARS: Adults/Children > 3 y.o.

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Patient age in MONTHS: for children < 3 y.o.

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Patient age in MONTHS or DAYS : babies < 1 y.o.

Please enter days if applicable.

Division at Stanford OHNS

Patient Sex

Attendings Involved

Attending not listed (First & Last Name)

Fellow/s involved

Resident/s involved (First & Last Name)

Location

Primary Diagnosis

Primary Procedure/Operation

Date of Event

mm/dd/yyyy

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Please provide a description of the event

Complications (Select as Many as Needed)

Suggestions for improvement

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Otolaryngology — Head & Neck SurgeryQuality Assurance