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Patient safety event:ID:Pt:^Event:Nom:AHRQ
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Date form completed
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{mm/dd/yyyy}
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Best description of the event or unsafe condition:Find:Pt:^Event:Nom:AHRQ
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Device involved in patient safety event or unsafe condition:Type:Pt:{Device}:Nom:AHRQ
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At the time of the event, the device was placed within the patient's tissue:Find:Pt:^Patient:Ord:AHRQ
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Event resulted in the device being removed:Find:Pt:^Event:Ord:AHRQ
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Device name
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Manufacturer name
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Device ID
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Model #
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Product version code:ID:Pt:Software:Nom:
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Vendor firmware version
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Serial #
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Lot or batch no.
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Other UDI [Type]
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Other UDI
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Expiration date
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{mm/dd/yyyy}
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UDI
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Asset tag number
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Device intended for single use was involved in the event or unsafe condition:Find:Pt:^Event:Ord:AHRQ
?
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Device intended for single use was reused in the event or unsafe condition:Find:Pt:^Event:Ord:AHRQ
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Medication or other substance was involved:Find:Pt:^Event:Ord:AHRQ
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Health information technology device was involved:Find:Pt:^Event:Ord:AHRQ
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Best characterization of health information technology device:Find:Pt:{Device}:Nom:AHRQ
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Administrative or billing system component:Type:Pt:Administrative or billing system:Nom:AHRQ
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Electronic health record system component:Type:Pt:Electronic health record:Nom:AHRQ
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Circumstances involving the health information technology device in the event or unsafe condition:Type:Pt:{Device}:Nom:AHRQ
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Problem that resulted from the equipment or device function problem:Type:Pt:{Device}:Nom:AHRQ
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Ergonomics or human &or device interface issue:Type:Pt:{Device}:Nom:AHRQ
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