Trauma Event Tracking Form

Demographics
Date of report: / Medical record No: / Admit Date:
Nature of event: / Date: Time:
Patient Name: / Age: / Gender:
Diagnosis:
Level of Activation:
Other Pertinent Information: / Report completed by:
Source of information (√)
Trauma nurse coordinators / PIPS coordinator / Conference
Physician / Rounds / Registry
Other
Impact (√)
Physical:
☐No harm
☐No detectable harm
☐Mild temporary harm
☐Mild permanent harm
☐Moderate temporary harm
☐Moderate permanent harm
☐Severe temporary harm
☐Severe permanent harm
☐Death / Psychological:
☐No harm
☐No detectable harm
☐Mild temporary harm
☐Mild permanent harm
☐Moderate temporary harm
☐Moderate permanent harm
☐Severe temporary harm
☐Severe permanent harm
☐Profound mental harm / Legal:
☐Risk management contacted
☐Complaint registered
☐Suit filed
☐Case dropped
☐Case dismissed
☐Settled
☐Defense Verdict
☐Plaintiff Verdict
Patient/family satisfaction:
☐Extremely satisfied
☐Satisfied
☐Neutral
☐Dissatisfied
☐Extremely dissatisfied / Social:
☐Unable to socialize
☐Homebound, able to socialize
☐No social impediments, not socially active
☐Socially active / Employment:
☐Employed
☐Seeking employment
☐Part-time employment
☐Unemployed
☐Not employable
Type (√)
Communication:
☐Inaccurate or incomplete information
☐Questionable advice &
☐Interpretation
☐Questionable consent process
☐Questionable disclosure process
☐Questionable documentation / Patient Management:
☐Airway
☐Breathing
☐Circulation
☐Neurologic
☐Gastrointestinal / ☐Nutritional
☐Urologic
☐Orthopedic
☐Delegation of care or tasks
☐Patient care flow/tracking
☐Patient follow-up / ☐Consultation or referral
☐Resource utilization
☐Resuscitation
☐Intensive care
☐Wound care
Clinical Performance
☐Pre-Interventional:
☐Correct diagnosis questionable intervention
☐Inaccurate diagnosis
☐Incomplete diagnosis
☐Questionable diagnosis / Interventional:
☐Correct procedure with complications
☐Correct procedure, incorrectly performed
☐Correct procedure but untimely
☐Omission of essential procedure
☐Procedure contraindicated
☐Procedure not indicated
☐Questionable procedure
☐Wrong patient / Post-Interventional:
☐Correct prognosis
☐Inaccurate prognosis
☐Incomplete prognosis
☐Questionable prognosis
Domain (√)
Setting: Hospital ☐Psychiatric Unit
☐Ambulatory care ☐Rehabilitation
☐Catheterization laboratory☐Other
☐Clinical ward Non-Hospital
☐Diagnostic procedures ☐EMS Transport vehicle
☐Emergency room ☐Home
☐Hospice ☐Hospice
☐Inpatient Mental Health ☐Long-Term Care facility
☐Inpatient Rehabilitation ☐Mental Health Facility
☐Intensive Care Unit ☐Nursing home
☐Interventional Radiology☐Practitioner’s office
☐Operating Room☐Psychiatric Hospital
☐Outpatient Behavioral Health☐Rehabilitation facility
☐Pharmacy☐Other facility
☐Physical Therapy☐Scene / Phase:
☐Evaluation
☐Resuscitation
☐Operative
☐Critical Care
☐Recovery
☐Rehabilitation / Target:
☐Cosmetic
☐Diagnostic
☐Other
☐Palliative
☐Preventative
☐Reconstructive
☐Rehabilitative
☐Research
☐Therapeutic
Domain (√) - continued
Staff:
☐Physicians
☐Intern
☐Resident
☐Attending
☐Dentist
☐Podiatrist
☐Physician assistant / Nurses:
☐Nurse’s aid
☐Licensed practical nurse
☐Registered nurse
☐Nurse Practitioner / Therapists:
☐Physical therapist
☐Occupational therapist
☐Speech therapist / Others:
☐Health professional student
☐Pharmacist
☐Pharmacy technician
☐Radiation technician
☐Optometrist
☐Other
System Factors (√)
Chain of command
☐Communication channels
☐Culture of safety
☐Delegation of authority and responsibility
☐Documentation
☐Equipment or materials availability
☐Equipment or materials design
☐Equipment or materials malfunction
☐Equipment or materials obsolescence
☐Establishment and use of safety programs
☐Formal accountability
☐Incentive systems
☐Instructions about procedure / Monetary safety budgets
☐Objectives
☐Organizational failures beyond the control of the organization
☐Performance standards
☐Risk management
☐Schedules
☐Selection of organizational resources
☐Staffing of organizational resources
☐Supervision
☐Technical failures beyond the control of the organization
☐Time pressures
☐Training
☐Training of organizational resources
Human Factors (√)
Patient factor
☐Practitioner skill-based
☐Practitioner rule-based
☐Practitioner knowledge-based
☐Practitioner unclassifiable / External
☐Negligence
☐Recklessness
☐Internal rule violations
☐Do not resuscitate order
☐Withdrawal of support
Prevention & Mitigation Activities
Universal:
☐Improve the accuracy of patient identification (P)
☐Improve the effectiveness of communication and caregivers (P) / ☐Improve the effectiveness of clinical alarm systems (P)
☐Reduce the risk of healthcare-acquired infections (M)
Indicated:
☐Improve the safety of using high-alert medications (P)
☐Improve the safety of using infusion pumps (P) / Selective:
☐Eliminate wrong-side, wrong site, wrong procedure surgery (M)
Action Plan and Loop Closure:
Signature: / Date: