Healthcare SUA Report

Healthcare SUA Report

Report Identifiers

Report ID:    Date of report:    Time of report:

Patient Information

DOB:    Gender:    MRN/ID:

Phone:    Emergency Contact:    Phone:

Event Details

Date of event:    Time of event:

Fall    Medication error    Equipment/device failure    Security/safety breach    Other

Immediate Care and Outcome

Yes    No

No apparent harm    Minor injury/temporary impairment    Moderate harm, intervention required    Serious harm or prolonged hospitalization    Death

Contributing Factors and Context

Staffing levels/workload    Communication breakdown    Equipment not functioning or unavailable    Medication labeling/packaging    Environmental hazards (floor, lighting)

Medications / Devices Involved

Witnesses and Reporter

Notifications and Regulatory Reporting

Attending physician    Risk Management/Quality    Patient/Family    Regulatory body (if applicable)

Corrective Actions and Follow-up

Assigned to:    Due date:

Privacy, Authorization and Legal Notice

This report contains protected health information necessary for internal investigation and patient care coordination. Information provided is subject to institutional confidentiality policies and applicable law. By signing below, the patient or authorized representative authorizes the release of relevant medical records and incident-related documentation to facility risk management, quality assurance, and regulatory reviewers for the purpose of investigation and corrective action. This authorization does not authorize release for unrelated purposes.

The facility retains investigation records for a period consistent with institutional retention policy. Knowingly providing false information on this report may subject the individual to administrative or legal action consistent with institutional policy and applicable law.

Acknowledgment by Patient or Authorized Representative

I acknowledge that the facts contained in this report have been explained to me to the best of the reporting staff's knowledge. I understand that investigation and review may occur and that relevant information from my medical record may be disclosed to authorized reviewers. I have been offered the opportunity to ask questions regarding the event and the investigatory process.

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