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PROS Learning from Errors in Ambulatory Pediatrics Study
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Appendix A
Learning from Errors in Ambulatory Pediatrics Study
Reporting Form
1. Please describe the error:
2. How long was it from when the error occurred to the time the error was recognized? (If your answer is not "Greater than 1 week", skip to question3.)____ Immediately
____ Within the same day
____ Not the same day, but 1 week or less
____ Greater than 1 week
____ Don't know
2a. If "Greater than 1 week" please enter the specific number of weeks.
____ weeks
3. How was the error discovered?
4. Who discovered the error? (Please select all that apply. Do not enter any names or identifiers in the "Other, specify" area.)____ I did
____ A physician other than me
____ Nurse, nurse's aid or medical assistant
____ Pharmacist
____ Lab tech
____ Parent
____ Transcriptionist
____ Other (please specify)
5. How often do you think this type of error happens to you while caring for patients?
____ This is the first time it has occurred
____ Seldom (1-2 times per year)
____ Sometimes (3-11 times per year)
____ Frequently (greater than or equal to once per month)
____ Don't know
6. Did the error result in any harm or injury for the patient? (If your answer is "No", skip to Question 7. If your answer is "Don't know", skip to Question 7.)
____ Yes
____ No
____ Don't know
6a. If "Yes", please describe the result of the error to the patient.
7. Do you know the age of the patient at the time of the error? (If your answer is "No", skip to Question 8.)____ Yes
____ No
7a. If "Yes", what was the age of the patient at the time of the error?
If patient was greater than one month old, enter your response here:
_____ years
_____ months (if known)
If patient was less than one month old, enter your response here:
_____ weeks
_____ days (if less than 1 week old)
8. What is the gender of the patient?
_____ Female
_____ Male
9. Is this patient Hispanic or Latino?____ Yes
____ No
____ Don't know
10. What is this patient's race? (Please select all that apply. Persons of Hispanic/Latino origin may be of any race therefore please respond to both Questions 9 and 10. Hispanic/Latino is not considered a race.)____ White
____ Black or African American
____ Asian
____ Native Hawaiian or Other Pacific Islander
____ American Indian or Alaskan Native
____ Don't know
11. At the time of the error, what was the health status of the patient? (If your answer is "No known health problems", skip to question 12.)____ No known health problems
____ Minor health problems (e.g., otitis media, pharyngitis)
____ Complex health problems (e.g., ADHD, asthma)
____ Complex health problems but child was being seen for a minor health problem (e.g., asthma but being seen for an ankle injury)
____ Don't know
11a. Please specify minor and/or complex health problems.
12. Please select one of the following categories concerning this patient:
____ I have never seen the patient before, and I am not familiar with his/her health problems
____ I have seen the patient before, but I am not familiar with his/her health problems
____ I am somewhat familiar with the patient and his/her health problems
____ I am quite familiar with the patient and his/her health problem
____ I am very familiar with the patient and his/her health problem
13. Please add any additional information about this incident that you feel might be important or might clarify it:
14. What additions, changes or suggestions would you make to this form, the process of accessing/submitting this form via the web or the study in general to help us improve this project?
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