Totally Anonymous Safety Report

Date the event occurred:

In which building did this incident occur?

Within the selected building, where did the event occur?

Age of patient:

ASA classification of the patient:

Shift during which the event occurred:

On the day this event occurred, how many hours did you sleep before coming to work?

When the event occurred, how many hours had you worked that week?

At the time the event occurred, how much time had passed since your last break?

At the time the event occurred, how much time had passed since your last meal?

Can you identify any personal factors from inside the hospital (unexpected change in clincial assignment, clinical assignment in an unfamiliar area, recent care handoff, loud music in OR, chatter in OR etc.) that contributed to this event?

Can you identify any personal factors from outside the hospital (family, home, illness, etc.) that contributed to this event?

Please describe the event in as much detail as possible. It is helpful to describe the event step by step as it happenned. You may upload photos, documents or movies related to the event using the 'drag files to upload' box below.

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How could this event be prevented in the future? Please provide as much detail as possible.

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