Trauma Event Tracking Form
Demographics
Date of report:
Nature of event:
Patient Name:
Diagnosis:
Level of Activation:
Other Pertinent Information:
Trauma nurse coordinators
Physician
Other
Medical record No:
Admit Date:
Date: Time:
Gender:
Age:
Report completed by:
Source of information (√)
PIPS coordinator
Rounds
Conference
Registry
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
Patient/family satisfaction:
☐Extremely satisfied
☐Satisfied
☐Neutral
☐Dissatisfied
☐Extremely dissatisfied
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
Social:
☐Unable to socialize
☐Homebound, able to socialize
☐No social impediments, not socially active
☐Socially active
Legal:
☐Risk management contacted
☐Complaint registered
☐Suit filed
☐Case dropped
☐Case dismissed
☐Settled
☐Defense Verdict
☐Plaintiff Verdict
Employment:
☐Employed
☐Seeking employment
☐Part-time employment
☐Unemployed
☐Not employable
Type (√)
Communication:
Patient Management:
☐Inaccurate or incomplete information
☐Airway
☐Nutritional
☐Consultation or referral
☐Questionable advice &
☐Breathing
☐Urologic
☐Resource utilization
☐Interpretation
☐Circulation
☐Orthopedic
☐Resuscitation
☐Questionable consent process
☐Neurologic
☐Delegation of care or tasks
☐Intensive care
☐Questionable disclosure process
☐Gastrointestinal
☐Patient care flow/tracking
☐Wound care
☐Questionable documentation
☐Patient follow-up
Clinical Performance
Interventional:
Post-Interventional:
☐Pre-Interventional:
☐Correct procedure with complications
☐Correct prognosis
☐Correct diagnosis questionable intervention
☐Correct procedure, incorrectly performed
☐Inaccurate prognosis
☐Inaccurate diagnosis
☐Correct procedure but untimely
☐Incomplete prognosis
☐Incomplete diagnosis
☐Omission of essential procedure
☐Questionable prognosis
☐Questionable diagnosis
☐Procedure contraindicated
☐Procedure not indicated
☐Questionable procedure
☐Wrong patient
Domain (√)
Setting: Hospital
☐Ambulatory care
☐Catheterization laboratory
☐Clinical ward
☐Diagnostic procedures
☐Emergency room
☐Hospice
☐Inpatient Mental Health
☐Inpatient Rehabilitation
☐Intensive Care Unit
☐Interventional Radiology
☐Operating Room
☐Outpatient Behavioral Health
☐Pharmacy
☐Physical Therapy
☐Psychiatric Unit
☐Rehabilitation
☐Other
Non-Hospital
☐EMS Transport vehicle
☐Home
☐Hospice
☐Long-Term Care facility
☐Mental Health Facility
☐Nursing home
☐Practitioner’s office
☐Psychiatric Hospital
☐Rehabilitation facility
☐Other facility
☐Scene
Phase:
☐Evaluation
☐Resuscitation
☐Operative
☐Critical Care
☐Recovery
☐Rehabilitation
Target:
☐Cosmetic
☐Diagnostic
☐Other
☐Palliative
☐Preventative
☐Reconstructive
☐Rehabilitative
☐Research
☐Therapeutic
Trauma Event Tracking Form
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)
Indicated:
☐Improve the safety of using high-alert medications (P)
☐Improve the safety of using infusion pumps (P)
☐Improve the effectiveness of clinical alarm systems (P)
☐Reduce the risk of healthcare-acquired infections (M)
Selective:
☐Eliminate wrong-side, wrong site, wrong procedure surgery (M)
Action Plan and Loop Closure:
Signature:
Date: