Anonymous Reporting Form | Laurel Health System

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Anonymous Reporting Form

Use for reporting of actual and near miss events. The goal is to increase reporting of actual events and near misses, and to identify potential safety problems before patients are harmed. Significant care practice changes can result from reporting of safety issues.

No individual reporting such issues will suffer any consequences for reporting safety issues. Any identifying data will not be disclosed.

* Denotes required field
* Patient Name:
* Medical Record Number:
* Location
* Date of Event
* Time
Did the event reach the patient?	Yes No
* Type of Event
If medication error, please provide name of drug, dose, and route
* Description of the event (what, when, and why)
Possible Causes	Critical patient information missing? Miscommunication Label/packaging problem Device problem Environmental, staffing or workflow problem Lack of staff education Patient education problem Lack of quality control or check problem Other:
* Patient Outcome
Reporter (optional)
* Captcha

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