Otolaryngology — Head & Neck SurgeryQuality Assurance

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*

Select

Santa Clara Valley Med Center ID

Patient MRN (Stanford)

VA only: provide last four digits of SSN

Patient age at the time of the Incident:

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

Please enter years.

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

Please enter months.

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

Please enter days if applicable.

Division at Stanford OHNS*

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Please specify which department/division was also involved

Patient Sex*

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Attendings Involved*

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Attending not listed (First & Last Name)

Fellow/s involved

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Resident/s involved (First & Last Name)

Location

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Other location

Primary Diagnosis*

Primary Procedure/Operation*

Date of Event*

Is this submission within 24 hours of event?*

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Reason it was not submitted within 24 hours

Please provide a description of the event*

Complications (Select as Many as Needed)*

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Other

Surgical Complications (Select as Many as Needed)*

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Medical Complications (Select as Many as Needed)*

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Suggestions for improvement

What is your email?*

Which person(s) should represent this case for QA?*

Presenter's email*

Send me a copy of my responses

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