CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY: INTAKE FORM – PHONE VERSION
Form
Approved
OMB No. 0935-XXXX
Exp.
Date XX/XX/20XX
Consumer Reporting System for Patient Safety
Phone Introduction and Screener Script
>INTRO<
Hello, you have reached the Consumer Reporting System for Patient Safety.
My name is [XXX]. I will be talking with you about your health care safety concern. First I will go over a few instructions with you.
>AGE<
To provide a report, you must be older than 18. Are you 18 years or older?
____ YES PROCEED
____ NO THANK and EXIT
>INTRO2<
Thank you for providing that information.
This interview will take about 20-25 minutes. We will ask you questions about the experiences you or your family members have had with health care. We will ask if you have ever had an experience where you think a mistake was made or where you had concerns about your safety. There are no right or wrong answers. If there are any questions you don't want to answer, tell me and we will just go on to the next one. You do not have to participate. You may change your mind and stop at any time, even after we start.
The Consumer Reporting System for Patient Safety (CRSPS) allows patients and their families to voluntarily report on the safety of their health care. CRSPS staff will use the information that you and others give us to understand patients’ concerns. CRSPS staff are researchers from the RAND Corporation and the ECRI Institute. We will only tell doctors, hospitals, and pharmacists a compilation of what we learn; no individual reports are shared. We hope they will make changes and that health care will be safer.
The information you give us is completely private. We will not use your name or your address or your phone number. Nobody will see your answers except people on the CRSPS team unless you say it is OK to share it. In some cases, my supervisor might listen to this call to make sure that I am doing a good job.
We will write a report about what we learn from the data collected in the system. We will give the report to doctors, hospitals, and pharmacists so they can do a better job and make health care safer. But we will combine all the answers we get from lots of people. Nobody will know the names of the people who helped us and nobody will be able to tell who said what.
The Consumer Reporting System for Patient Safety was paid for by an agency that is part of the United States government. The agency is called the Agency for Healthcare Research and Quality. It has strict laws about protecting patients’ privacy.
You will not receive any payment or any other direct benefits for your help. But by sharing your story, you can help make health care safer for the people in your town and in towns all across the United States.
>PHONE<
Would you mind giving me your phone number? If our phone call gets disconnected, I will call you right back.
ENTER TELEPHONE NUMBER: ( ______) _____ - ________
Ask:
Do you have any questions? [If so, refer to FAQs list]
Do you understand everything I said or is there anything I should go over again?
May I use a tape recorder as we talk so I remember what you tell me exactly right?
____ YES START RECORDING “Thanks. I’ll start recording now.”
____ NO “Thanks. I will take notes only but not record our conversation.”
I am ready to ask you questions about your health care safety concern. Are you ready to begin?
SECTION 1: INTRODUCTION
The Consumer Reporting System for Patient Safety enables patients and others to describe concerns about the safety of their health care. “Safety concerns” include medical mistakes and injuries related to health carenegative effects. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications. Safety concerns might come up during a visit to a doctor’s office, at a pharmacy, or in the hospital.
Complaints about services like food or parking should not be reported here. Please refer to the resources link on the home page for where to report those in your area.
It should take about 10-15 minutes to complete a report. You may skip any question by leaving it blank. The more information you provide, the more we can learn from your experience.
You will have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the negative effect. This would alert the facility’s staff so they can learn about what went wrong and improve safety.
Public
reporting burden for this collection of information is estimated to
average 25
minutes per response, the estimated time required to complete
the survey. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-XXXX)
AHRQ,
540 Gaither Road, Room # 5036, Rockville, MD 20850.
1.1 Who is the patient with a safety concern?
□A Me
□B A child
□C A spouse, domestic partner or other family member (for example, a grandparent, aunt, etc.)
□D A friend
□E A patient or client
□F Someone else [DISPLAY AS TEXT BOX: Who is the patient? ALLOW 50]
1.1.1 In what city and state did the safety concern occur?
Enter the city: ___________________________________
Enter the State: __________
SECTION 2: DESCRIPTION OF YOUR SAFETY CONCERN
2.1 Please tell us about the safety concern.
2.1a. What happened?
2.1b. Where did it happen?
2.1c. When did it happen?
2.1d. Why did it happen?
2.2 What is the name of the patient?
ENTER FIRST NAME: ___________________________
ENTER LAST NAME: ___________________________
Now we will ask some questions to make sure we understand what happened.
2.3 In your opinion, did a doctor, nurse, or other health care provider make a medical mistake or error in the patient’s care?
AS NEEDED: A medical mistake or error is something that was done (or not done) by a health care provider that would be considered incorrect at the time it happened. Sometimes medical mistakes can result in harm or injury to the patient, but not every time.
□A Yes GO TO 3.1
□B No GO TO 2.3.1
□C Don’t know GO TO 2.3.1
** When people are harmed or injured as a result of medical care, we call this a negative effect. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications.
2.3.1 Did a negative effect take place as a result of the patient’s care?
□A Yes GO TO 4.1
□B No GO TO 2.2.1.1
□C Don’t know GO TO 2.2.1.1
2.3.1.1 You told us that a mistake did not take place (or that you don’t know) and that a negative effect did not take place (or that you don’t know). Is this correct?
□A Yes GO TO 6.1
□B No GO TO 6.1
C Don’t know GO TO 6.1
PROGRAMMER NOTE: SECTION 3 TO BE ASKED ONLY IF ITEM 2.2=YES. IF RESPONSE IS “NO” OR “DON’T KNOW” SKIP TO SECTION 4.
SECTION 3: MISTAKE
3.1 Did the medical mistake or error involve any of the following? Please choose the one answer that fits best.
□A A mistake related to a medicine
[AS NEEDED: Medicines can include prescription or non-prescription medication, herbs, dietary supplements, vaccines, contrast dye or other injected medicines] GO TO 3.1.1.1
□B A mistake related to a test, procedure, or surgery
[AS NEEDED: This includes tests that involve taking samples of skin or tissue, inserting tubes to examine internal parts of your body, or other tests involving blood, urine, or X-rays.] GO TO 3.1.2.1
□C A mistake related to pregnancy or childbirth
[AS NEEDED: This includes errors in diagnostic testing during pregnancy and errors during labor and delivery] GO TO 3.2
□D A mistake related to a diagnosis or advice from a doctor, nurse, or other health care provider GO TO 3.1.3.1
□E A mistake related to poor cleanliness or poor hygiene GO TO 3.2
□F Something else, or more than one mistake [GO TO 3.1f1]
3.1.f1 What was the mistake?
3.1.1.1 As best as you can, please name or describe the medicine. [PROGRAMMER NOTE: PROGRAM FREE TEXT BOX. ALLOW 50.]
3.1.1.2 Was it a prescription medicine?
[AS NEEDED: Don’t include over-the-counter medicines that you can buy without a prescription from a doctor or nurse.]
□A Yes
□B No
□C Don’t know
3.1.1.3 Did the mistake with medicine involve any of the following? Please choose the one answer that fits best.
□A Wrong medicine GO TO 3.2
□B Wrong dose GO TO 3.2
□C Something else GO TO 3.1.1.3-OTHER
3.1.1.3-OTHER: What did the mistake involve?
As best as you can, please name or describe the test, procedure, or surgery.
3.1.2.2 Did the mistake with a test, procedure, or surgery involve any of the following? PLEASE CHECK ALL THAT APPLY.
PROGRAMMER: FOR EACH ITEM CHECKED, CODE AS “1”. DEFAULT WILL BE “0” IF LEFT BLANK.
□A Wrong patient [POP UP: The patient was not correctly identified.]
□B Wrong test, procedure, or surgery [POP UP: The wrong type of test, procedure, or surgery was done.]
□C Wrong part of the body [POP UP: The test, procedure, or surgery was on the wrong part of the body.]
□D A mistake was made during the test, procedure, or surgery
□E The test, procedure, or surgery was delayed
□F The test results were lost and the patient did not receive them
□G The patient developed an infection
□H A problem with anesthesia
□I Something else [What did the mistake involve? [FREE TEXT BOX. ALLOW 50]
GO TO 3.2 ONCE ITEMS CHECKED
3.1.3.1 In your opinion, what was the mistake with the diagnosis or medical advice?
3.2 Where did the mistake happen? Please choose the one answer that fits best.
□A In a doctor’s office or a clinic
□B In a pharmacy
□C In the emergency department
□D In a hospital
□E At home
□F Somewhere else [Where? FREE TEXT BOX]
□G Don’t know
3.3 Would you like to tell us the name and address of the health care doctor, nurse, or other health care provider (or the health care facility) involved in the mistake? PROGRAMMER NOTE: SELECT 1
□A Yes
□B Yes, but I do not know the name and address of the provider GO TO 3.4
□C No, I do not know the name and address of the provider GO TO 3.4
□D No, I do not want to tell you GO TO 3.4
3.3.1 Please write the name and address of the health care provider (or facility) involved in the mistake. [PROGRAMMER: PROGRAM FOLLOWING FREE TEXT BOXES]
NAME OF PROVIDER/ HEALTH CARE FACILITY:
______________________________________________________________________
STREET ADDRESS: ___________________________________________________
CITY: ____________________________ STATE: _____
3.3.2 Was a second health care provider (or facility) involved?
□A Yes
□B No GO TO 3.3.5
3.3.3 Would you like to tell us the name and address of the second health care provider (or facility) involved in the mistake?
□A Yes
□B Yes, but I do not know the name and address of the provider GO TO 3.3.5
□C No, I do not know the name and address of the provider GO TO 3.3.5
□D No, I do not want to tell you GO TO 3.3.5
3.3.4 Please write the name and address of the second health care provider (or facility) involved in the mistake.
NAME OF PROVIDER/ HEALTH CARE FACILITY:
______________________________________________________________________
STREET ADDRESS: ___________________________________________________
CITY: ____________________________ STATE: _____
You have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the mistake. This would alert the facility’s staff so they can learn about what went wrong and improve safety.
3.3.5 May we share your report with the health care provider (or facility) you identified?
□A Yes
□B No
3.4 In what month and year did the mistake happen? (Your best estimate is fine.)
ENTER MONTH: PROGRAM SCROLL DOWN WITH MONTHS LISTED
ENTER YEAR: PROGRAM SCROLL DOWN WITH YEARS LISTED (ALLOW 10 YEARS BEFORE ACTUAL YEAR)
3.5 Did a doctor, nurse, or other health care provider tell you the mistake happened?
□A Yes GO TO 3.6
□B No
3.5.1 How did you find out that the mistake happened? [PROGRAMMER NOTE: PROGRAM FREE TEXT BOX.]
Sometimes medical mistakes affect patients financially. For example, patients may have to miss work, pay for extra tests or procedures, or take additional trips to a health care facility.
3.6 Did the mistake affect the patient financially?
□A Yes
□B No
□C Don’t know
When people are harmed or injured as a result of medical care, we call this a negative effect. Negative effects can be physical or emotional and they may include infections, drug reactions, or other complications.
3.7 Did the patient experience any negative effects as a result of the mistake or error?
□A Yes
□B No GO TO 5.1
□C Don’t know GO TO 5.1
SECTION 4: NEGATIVE EFFECT
INTERVIEWER NOTE: IF QUESTION 2.2=YES, DO NOT READ ANY OF THE QUESTIONS THAT HAVE DOUBLE ASTERISKS (**).
IF QUESTION 2.2 WAS “NO” OR “DON’T KNOW” OR LEFT BLANK AND YOU DID NOT ASK ANY QUESTIONS IN SECTION 3 ( WAS NOT ANSWERED) THEN ALL QUESTIONS IN THIS MODULE SHOULD BE ASKED.
4.1 **Did the negative effect involve any of the following? Please choose the one answer that fits best.
□A A negative effect related to a medicine
□B A negative effect related to a test, procedure, or surgery
□C A negative effect related to pregnancy or childbirth
□D A negative effect related to a diagnosis or medical advice
□E Unclean or unsanitary care
□F Something else or more than one negative effect
[What did it involve? _______________________________________
___________________________________________________________
___________________________________________________________
4.2 What kind of negative effect did the patient experience?
□A Physical
□B Emotional GO TO 4.4
□C Both
4.3 What kind of physical negative effect did the patient experience? PLEASE CHECK ALL THAT APPLY.
□A Dizziness
□B Sick to the stomach (nausea)
□C Infection
□D Pain
□E A fall that caused an injury
□F Open sores on skin
□G A sexual problem
□H Blood clot
□I Uncontrolled bleeding
□J Breathing difficulty
□K Numbness or weakness
□L Injury to teeth
□M Injury to an eye
□N Burn
□O Heart attack or stroke
□P Other physical effect [Please describe. ____________________________
_________________________
_________________________
□Q The negative effect was not physical.
4.4 **Where did the negative effect first happen? Please choose the one answer that fits best.
□A In a doctor’s office or a clinic
□B In a pharmacy
□C In the emergency department
□D In a hospital
□E At home
□F Somewhere else [Where did this first happen? ____________________
_______________________________________________
_______________________________________________
□G Don’t know
4.5 **Would you like to tell us the name and address of the doctor, nurse, or other health care provider (or health care facility) involved in the negative effect? PROGRAMMER NOTE: SELECT 1
□A Yes
□B Yes, but I do not know the name and address of the provider GO TO 4.6
□C No, I do not know the name and address of the provider GO TO 4.6
□D No, I do not want to tell you GO TO 4.6
4.5.1 **Please write the name and address of the health care provider (or facility) involved in the negative effect.
NAME OF PROVIDER/ HEALTH CARE FACILITY:
______________________________________________________________________
STREET ADDRESS: ___________________________________________________
CITY: ____________________________ STATE: _____
4.5.2 **Was another health care provider (or facility) involved?
□A Yes
□B NoGO TO 4.5.5
4.5.3 Would you like to tell us the name and address of the second health care provider (or facility) involved in the negative effect?
□A Yes
□B Yes, but I do not know the name and address of the provider GO TO 4.6
□C No, I do not know the name and address of the provider GO TO 4.6
□D No, I do not want to tell you GO TO 4.6
4.5.4 **Please write the name and address of the second health care provider (or facility) involved in the negative effect.
NAME OF PROVIDER/ HEALTH CARE FACILITY:
______________________________________________________________________
STREET ADDRESS: ___________________________________________________
CITY: ____________________________ STATE: _____
**You have the option to give permission for the Consumer Reporting System for Patient Safety staff to share your report with any doctor, nurse, or other health care provider (or facility) that was involved in the negative effect. This would alert the facility’s staff so they can learn about what went wrong and improve safety.
4.5.5 **May we share your report with the health care provider (or facility) you identified?
□A Yes
□B No
4.6 **In what month and year did the negative effect happen? (Your best estimate is fine.)
ENTER MONTH: __________
ENTER YEAR: ___________
4.7 Did the patient get additional medical testing or treatment because of the negative effect?
□A Yes
□B No
□C Don’t know
4.8 How did the patient find out that the negative effect happened? Please choose the one answer that fits best.
□A The patient noticed it.
□B A friend or family member noticed it and told the patient.
□C A doctor, nurse, or other health care provider told the patient about it.
□D An administrator or manager told the patient about it
□E The patient found out in some other way. [How did patient find out? _____________________________________________________________
_____________________________________________________________
□F The patient never knew about it.
4.9 Did a doctor, nurse, or other health care provider make any special effort to help the patient handle the negative effect?
□A Yes
□B No GO TO 4.10
□C Don’t know GO TO 4.10
4.9.1 How helpful were they?
□A Extremely helpful
□B Very helpful
□C Somewhat helpful
□D Slightly helpful
□E Not at all helpful
4.10 Did the negative effect cause the patient to miss work, school, or other regular activities?
□A Yes
□B No
□C Don’t know
**Sometimes patients experience negative financial effects. For example, patients may have to miss work, pay for extra testing or treatment, or take additional trips to a health care facility.
4.11 **Did the negative effect cause financial problems for the patient?
□A Yes
□B No
□C Don’t know
SECTION 5: CONTRIBUTING FACTORS, CHANGES IN CARE,
DISCOVERY, & REPORTING
Now we will ask some questions about why the mistake or negative effect happened, and what the patient did afterward.
5.1 In your opinion, could anything have been done differently to prevent this mistake or negative effect from happening? PROGRAMMER NOTE: SELECT 1
□A Yes [What could have been done? ___________________________________________________________________________________________________________________________________]
□B No
□C Don’t know
5.2 Why do you think this mistake or negative effect happened?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
5.3 In your opinion, did any of the following lead to the mistake or negative effect? PLEASE CHECK ALL THAT APPLY.
Communication with doctors, nurses or other health care providers
5.3.1 Was it because the doctors, nurses, or other health care providers…
□A did not listen to the patient?
□B did not explain things to the patient in the patient’s language?
□C used terminology the patient could not understand?
□D did not spend enough time with the patient?
□E spoke with an accent that was hard to understand?
□F ignored what the patient told them?
□G did not explain medications or their side effects?
□H did not explain follow up care instructions?
Responsiveness of staff
5.3.2 Was it because of not getting…
□A help as soon as the patient needed it?
□B a referral as soon as the patient needed it?
□C an appointment as soon as the patient needed it?
□D care as soon as the patient needed it?
Coordination of care
5.3.3 Was it because…
□A the doctors, nurses, or other health care providers were not aware of care that took place someplace else?
□B of the lack of follow up by the doctors, nurses, or other health care providers?
□C doctors, nurses, or other health care providers did not seem to work well together as a team?
Access
5.3.4 Was it because the patient…
□A was not able to get in to see a specialist for care?
□B was not able to get the tests or treatments that the patient believed necessary?
□C was not able to get the tests or treatments that a provider believed necessary?
□D did not get help or advice they needed?
Verification
5.3.5 Was it because someone did not…
□A correctly identify the patient?
□B have the most recent and up-to-date information about the patient?
Other
5.3.6
Was it because the patient…
□A couldn’t afford the care the patient believed necessary?
□B couldn’t afford the care a provider believed necessary?
□C had no insurance to pay for the care the patient believed necessary?
□D had no insurance to pay for the care a provider believed necessary?
5.4 Did this mistake or negative effect cause the patient to switch to a different doctor, nurse, or other health care provider, or transfer to a different medical facility? PLEASE CHECK ALL THAT APPLY.
□A Yes – Switched to a different health care provider
□B Yes – Transferred to a different hospital
□C Yes – Transferred to a different pharmacy
□D Yes – Other [What was the switch? FREE TEXT BOX. ALLOW 50]
□E No – There was no change
5.5 Did the patient tell anyone about the mistake or negative effect?
□A Yes
□B No GO TO 6.1
□C Don’t know GO TO 6.1
5.5.1 Who did the patient tell about the mistake or negative effect? PLEASE CHECK ALL THAT APPLY.
□A A family member or friend
□B A doctor, nurse, or other health care provider
□C A health care administrator or manager
□D Someone at the pharmacy
□E A minister or other religious leader
□F A lawyer
□G Someone else GO TO 5.4.other
5.5.1other Who did the patient tell?
_________________________________________________________________
_________________________________________________________________
SECTION 6: CLINICIAN/FACILITY & PATIENT INFORMATION
A member of the Consumer Reporting System for Patient Safety staff can follow up by telephone. Please give us your name and how to reach you. We will make sure that your name and other contact information is kept secure. It will be shared only with your permission. If you decide NOT to give us your contact information, we will not contact you in the future.
6.1 May we contact you if we need more information?
□A Yes
□B No GO TO 6.2
6.1.1 Please tell us your name and your address, telephone number, or email.
Your name: _________________________________________
Your address: _________________________________________
City: _________________________________________
State: _________________ Zipcode: _______________ (allow 5)
Your phone number: (_____) ______-_________
This is your…
□A Home number
□B Work number
□C Cell number
Your email address:
_________________________________@____________________.____
NOTE TO INTERVIEWER: BE SURE TO READ EMAIL LETTER BY LETTER.
6.1.2 Is it better to reach you on weekdays or weekends?
□A Weekday □B Weekend
6.1.3 What is the best time of day to reach you?
□A Morning □B Afternoon □C Evening
[INTERVIEWER ASK Q 6.1.4 ONLY IF ANSWER TO 3.3.4 OR 4.4.4= YES. OTHERWISE SKIP]
6.1.4 When we contact the doctor, nurse, or other health care provider (or facility) to share your report, may we include your name and contact information? This will help the provider or facility match your report with their records. The provider or facility will not contact you.
□A Yes
□B No
Our last questions will help us to understand whether some people are more likely than others to experience medical mistakes and negative effects.
6.2 What is the patient’s sex?
□A Male
□B Female
6.3 At the time of the mistake or negative effect, approximately how old was the patient?
Age of patient at time of mistake or negative effect: __________
Note: If the patient was a child and less than 1 year, enter 1 year.
6.4 Is the patient Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)
□A No
□B Yes, Mexican, Mexican American, Chicano/a
□C Yes, Puerto Rican
□D Yes, Cuban
□E Yes, another Hispanic, Latino, or Spanish Origin
6.5 What is the patient’s race? (One or more categories may be selected)
□A White
□B Black or African American
□C American Indian or Alaska Native
□D Asian Indian
□E Chinese
□F Filipino
□G Japanese
□H Korean
□I Vietnamese
□J Other Asian
□K Native Hawaiian
□L Guamanian or Chamorro
□M Samoan
□N Other Pacific Islander
□O Vietnamese
6.6 [TBD: Add an additional question about race/ethnicity tailored to the demographics of the specific community]
6.7 What type of health insurance did the patient have at the time of the mistake or negative effect? Please choose the one answer that fits best.
□A Private insurance through an employer
□B Private insurance that the patient bought
□C Medicare
□D Medicaid (including Medicaid managed care plans)
□E Other 6.7eTYPE: What type is it? ______________________________
□F Not insured (Please select this only if you have not picked any other answer)
□G Don’t know
□H I do not wish to disclose this information.
6.8 How did you learn about the Consumer Reporting System for Patient Safety? Please choose the one answer that fits best.
□A A doctor, nurse, or other health care provider’s website
□B A flyer or poster in a doctor’s office, clinic, hospital, emergency department, pharmacy, or other health care facility
□C A computer kiosk in a doctor’s office, clinic, hospital, emergency department, pharmacy, or other health care facility
□D A conversation with a doctor, nurse, or other health care provider
□E Mailed materials from a doctor, nurse, or other health care provider
□F Other How did you learn about the system? ______________________
________________________________
________________________________
>THANKS<
Thank you for your report and for helping to improve patient safety.
.
| File Type | application/msword |
| File Title | COVER PAGE |
| Author | Lauren Hunter |
| Last Modified By | Denise Quigley |
| File Modified | 2013-05-01 |
| File Created | 2013-04-30 |